Pulmonary complications in anterior-posterior thoracic lumbar fusions

doi:10.1016/j.spinee.2003.11.008

The Spine Journal

Volume 4, Issue 3, May–June 2004, Pages 312-316

https://doi.org/10.1016/j.spinee.2003.11.008 Get rights and content

Abstract

Background context

Surgery for adult spinal deformity may require both an anterior and posterior approach in order to stabilize the spine and achieve the desired correction. These procedures can be associated with significant pulmonary complications, including atelectasis, pneumonia and respiratory failure. The etiology of some of the respiratory complications is clear: poor inspiratory effort from incision pain and previous pulmonary disease. However, for many patients the direct cause of these complications is not obvious.

Purpose

To delineate the incidence, severity and risks associated with pulmonary complications in the setting of major spine surgery.

Study design/setting

Retrospective chart review study of adult patients undergoing combined anterior-posterior thoracic, lumbar and sacral fusion spine surgery.

Patient sample

A total of 60 charts were reviewed for this study.

Outcome measures

Radiographic abnormalities correlated with clinical findings, postoperative need for ventilation and lengths of hospital stay were used as outcome measures.

Methods

Perioperative pulmonary complications were assessed for 60 patients with spinal deformities who underwent combined anterior-posterior thoracic, lumbar and sacral fusion over a 2-year period.

Results

One patient was eliminated from analysis because of multiple surgeries during his hospital course. Of the remaining 59 patients, 38 (64%) developed roentgenographic abnormalities. The most common radiographic finding was an effusion found in 66% of these patients, followed by atelectasis in 53%. Twenty-one percent (8 of 38) had infiltrates. Five (5 of 38) or 13% had evidence of partial or complete lobar collapse; in two bronchoscopy was required because of profound hypoxemia. Two patients had pneumonia requiring antibiotic treatment. All but two patients were extubated within 36 hours of surgery. They were kept intubated because of hemodynamic instability. There was no statistically significant difference in the group of patients with and without roentgenographic abnormalities with regard to age, weight, American Society of Anesthesiologists class, smoking history, pulmonary function test results, blood loss, perioperative blood and crystalloid requirement and length of surgery. Patients with radiographic abnormalities were more likely to have had invasion of their thoracic cavity (p=.02) and had a longer mean hospital stay of 13.5 versus 10.2 days (p=.009).

Conclusion

Radiographic abnormalities of the lungs are common after major spine surgery involving both an anterior and posterior approach, especially when the thoracic cavity is invaded. In view of the morbidity and longer hospital stay associated with such findings, close monitoring of pulmonary status with aggressive pulmonary toilet are indicated.

Introduction

Postoperative pulmonary complications are important considerations in some types of surgery, especially abdominal and thoracic surgery [1], [2]. Their frequency increases with the duration of anesthesia and surgery, which may increase morbidity and prolong hospital stay [3]. Corrective surgery for spinal deformities can be lengthy and may involve sequential anterior and posterior approaches with incisions extending into the upper abdominal wall and thoracic cavity. Concomitant restrictive lung disease from scoliosis and other preexisting pulmonary conditions may also increase the risks [4], [5]. We undertook this study to assess the incidence, severity, possible cause and type of pulmonary complications occurring in patients undergoing anterior and posterior corrective spine surgery during the same day.

Section snippets

Methods

With institutional review board approval, we retrospectively reviewed a total of 60 charts of consecutive patients who underwent sequential anterior posterior thoracolumbosacral corrective surgery the same day for spinal deformities over a 2-year period. The anterior incision, which was made in the lateral decubitus position, extended either into the upper abdominal wall or into the thoracic cavity. All patients received a general anesthetic of nitrous oxide-fentanyl, with 0.2% forane as a

Results

Of the 60 patient charts reviewed, one patient was omitted from analysis after requiring four surgeries during a single extended hospital stay for stabilization of the spine. Of the 59 remaining subjects, there were 48 women and 11 men with a mean age of 46±15 years (Table 1). Comorbidities are listed in Table 2. Kyphoscoliosis and scoliosis were the most common indications for surgery in the patient population (Table 3). The other patients had flat back syndrome. Thirty-eight patients (64%)

Discussion

Radiographic abnormalities of the chest are common after major spine surgery involving both an anterior and posterior approach. Effusions are most common, and their locations did not correlate with the side of thoracic incision or chest tube placement. Their etiology may be related to diaphragmatic manipulation or irritation during surgery. Fluid overload could also be a contributing factor because they were bilateral in 48% of these patients, and some responded to diuresis. Atelectasis is the

Acknowledgements

We acknowledge that this is a retrospective study, but this type of review can only underestimate the incidence of pulmonary complications. However, we found roentgenographic abnormalities to be very common after major spine surgery involving both an anterior and posterior approach especially when the thoracic cavity is invaded. In view of the morbidity and longer hospitalization stay associated with those findings, close monitoring of pulmonary status with aggressive pulmonary toilet are

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2020, Clinical Neurology and Neurosurgery
Citation Excerpt :
Risk factors for these complications have been examined across the literature in fusion procedures and in corrective surgery for scoliosis. Some of these risk factors have included age, operation time, blood transfusion volume, reoperation and preoperative pulmonary disease [22,23], although not all of these factors are universally agreed upon [20]. While a high BMI is a known risk factor for atelectasis, a meta-analysis examining the impact of BMI on surgical outcomes following cervical fusion did not find a significant difference in pulmonary complications between high and low BMI groups [29].
Chronic opioid use (COU) remains on the rise globally, acting as a marker for patient morbidity and a risk factor for adverse health outcomes. Opioid use is a risk factor for respiratory depression, which may lead to dysfunctional breathing, a known cause of atelectasis. The objective of this study was to determine whether COU is associated with increased rates of postoperative atelectasis among patients undergoing lumbar fusion.
Three State Inpatient Databases were used to identify patients who underwent an elective lumbar fusion through an anterior, posterior or circumferential approach in Florida, Kentucky and New York between 2013−2015. Patients with COU and those with postoperative atelectasis were identified using ICD diagnosis codes. Three operative groups were created and subsequently matched using propensity scores in order to provide comparable cohorts for analysis. Three-to-one propensity score matching was conducted using the variables of age, sex, race, number of chronic diagnoses and geographic state of admission. Multivariable logistic regressions were used to examine the relationship between COU and postoperative atelectasis.
A total of 3618 lumbar fusions were identified. Atelectasis was noted in 1.33 % of NCOU patients and 2.32 % of COU patients. On multivariable analysis, while controlling for the Elixhauser Mortality Index and patient insurance status, COU was significantly associated with atelectasis in posterior lumbar fusion (OR = 2.27; CI: 1.09–4.72; p = 0.028) and circumferential lumbar fusion (OR = 4.68; CI: 1.52–14.45; p = 0.007). The Elixhauser Mortality Index was also significantly associated with atelectasis in posterior lumbar fusion (OR = 1.08; CI: 1.04–1.11; p < 0.001) and circumferential lumbar fusion (OR = 1.09; CI: 1.03–1.16; p = 0.002).
Higher rates of postoperative atelectasis were found among patients with COU following posterior and circumferential lumbar fusions. The Elixhauser Mortality Index was also independently associated with atelectasis. Knowledge of these risks may allow for earlier identification and intervention in patients who are at risk.
Postoperative complications in adult spinal deformity patients with a mental illness undergoing reconstructive thoracic or thoracolumbar spine surgery
2019, Spine Journal
Citation Excerpt :
The relative increase in postoperative respiratory complication rates in adult spinal deformity patients with depression and/or anxiety has not been previously reported. Previous studies have found no clear risk factors for the development pulmonary complications following thoracic spinal surgery [24,27]. We hypothesize that the increase in respiratory complications may be attributed to poor postoperative compliance in using an incentive spirometer and following other prophylactic measures.
Previous studies have found an association between mental illness and poor outcomes in spine surgery, but little is known about the effects of depression and/or anxiety on the adult spinal deformity population. In addition, most relevant studies exclusively focused on the lumbar spine and had relatively small patient sizes.
The aim of this study was to investigate whether adult spinal deformity patients with depression and/or anxiety have an increased risk of postoperative complications and reoperation following posterior thoracolumbar spinal surgery.
Retrospective database study.
Adult patients (over 18 years of age) with a diagnosis of spinal deformity undergoing any reconstructive thoracic or thoracolumbar spinal procedure with a posterior approach between 2007 and 2015 Q2 were identified using Current Procedural Terminology codes to query the Pearl Diver patient record database (Pearl Diver Technologies, West Conshohocken, PA, USA). The database includes records of approximately 18 million patients across the United States having Humana insurance. Further selection of patients with depression and/or anxiety and their associated postoperative complications were identified using ICD-9 and ICD-10 diagnosis codes (International Classification of Diseases 9th-10th edition). The mental illness cohort was matched to a control group according to age, sex, and Charlson Comorbidity Index. Patient data was analyzed for reoperation rates and incidence of common postoperative complications.
Multilevel posterolateral fusion was the most common included posterior thoracic reconstructive surgery. The mental illness cohort (n = 327) had significantly increased rates of infection (odds ratio [OR] = 1.743, p = .022) and respiratory complications (OR = 1.492, p = .02) at the 90-day postoperative period. The rates of incision and drainage (OR = 1.379, p = .475) and pneumonia (OR = 1.22, p = .573) were increased in the mental illness cohort at the 90-day postoperative period, but not significantly. There were no significant differences in complication and reoperation rates at 1-year postoperatively.
Patients with spinal deformity and pre-existing depression and/or anxiety treated with a posterior thoracolumbar reconstructive spinal surgery had significantly elevated risk of postoperative infections and respiratory complications when compared with the control group.
Treatment Algorithms and Protocol Practice in High-Risk Spine Surgery
2013, Neurosurgery Clinics of North America
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As much as 68% of the population older than 60 years has been shown to have some form of spinal deformity, and limitation in activity and overall disability are the most powerful factors driving individuals to surgery.10 The overall complication rate in adult revision spinal surgery has been reported to be as high as 40%, and the factors associated with the highest rate of complication include patient age, medical comorbidities, and extension of fusion to the sacrum.3,4,11–15 Because of the lack of physiologic reserve and multiple medical comorbidities, the complication rate can be even higher in the elderly population.2,3
Protocol Practice in Perioperative Management of High-Risk Patients Undergoing Complex Spine Surgery
2012, Spine Deformity
Citation Excerpt :
Adult deformity operations have been shown to have a complication rate as high as 40% [1,12-14]. Glassman et al. point out that the risk factors associated with complications in adult deformity surgery include patient age, medical comorbidities, and extension of fusion to the sacrum [1,11,14-16]. In the elderly population, the complication rate can be even greater, thus mandating even more rigorous preoperative testing.
The treatment of complex spinal pathology is an often technically challenging endeavor that places a high physiological stress on the patient. While outcomes from successful deformity correction operations across a wide range of ages have demonstrated a significant improvement in quality of life, the patient must be medically fit to undergo such a procedure. The Northwestern high-risk spine protocol has been developed in order to thoroughly evaluate and treat patients in the pre-, intra-, and postoperative periods to optimize outcomes. The use of evidence based, protocol driven management strategies has been shown to improve outcomes in many aspects of medicine. The institution of such a high-risk protocol in complex spinal surgery enables the patient care team to fully assess the risk profile for a given patient and helps guide management, particularly in the setting of physiologically demanding procedures with high complication rates, such as adult deformity correction.
The effect of low versus high tidal volume ventilation on inflammatory markers in healthy individuals undergoing posterior spine fusion in the prone position: A randomized controlled trial
2012, Journal of Clinical Anesthesia
Citation Excerpt :
Other studies performed in healthy individuals undergoing thoracic, abdominal, and cardiac surgery failed to show a benefit of a protective ventilation strategy, suggesting that the type of surgery may also contribute to the perioperative inflammatory response [3,4]. The impact of the protective ventilation strategy has not been studied in patients undergoing spine surgery, a cohort who may be prone to lung injury secondary to intraoperative insults, including pulmonary embolization [5-9]. While it is difficult to influence factors related to surgical insults of the lung, manipulation of ventilator strategies is possible.
To evaluate the effect of ventilation strategy on markers of inflammation in patients undergoing spine surgery in the prone position.
Randomized controlled trial.
University-affiliated teaching hospital.
26 ASA physical status 1 and 2 patients scheduled for elective primary lumbar decompression and fusion in the prone position.
Patients were randomized to receive mechanical ventilation with either a tidal volume (V_T) of 12 mL/kg ideal body weight with zero positive end-expiratory pressure (PEEP) or V_T of 6 mL/kg ideal body weight with PEEP of 8 cm H₂O.
Plasma levels of interleukin (IL)-6 and IL-8 were determined at the beginning of ventilation and at 6 and 12 hours later. Urinary levels of desmosine were determined at the beginning of ventilation and on postoperative days 1 and 3.
A significant increase in IL-6, IL-8, and urine desmosine levels was noted over time compared with baseline (P < 0.01). However, no significant difference in the levels of markers was seen between the groups at any time point when controlling for demographics, ASA physical status, body mass index, duration of ventilation, or estimated blood loss.
Although markers of inflammation are increased after posterior spine fusion surgery, ventilation strategy has minimal impact on markers of systemic inflammation.
Assessment of related surgical complications of minimally invasive retropleural approach to the thoraco-lumbar spine
2019, Revista Espanola de Cirugia Ortopedica y Traumatologia
Revisar las complicaciones asociadas al abordaje retropleural mínimamente invasivo utilizado en el abordaje anterior a la columna toracolumbar.
Se presenta la técnica quirúrgica y la evaluación de datos recogidos de manera prospectiva de la serie inicial de 31 pacientes intervenidos. Se evalúa la apertura de pleura durante el abordaje, las complicaciones pulmonares derivadas, otras complicaciones quirúrgicas, el tiempo de intervención, el sangrado intraoperatorio, la necesidad de transfusión y la estancia hospitalaria.
La edad media de los pacientes fue de 58 años, el tiempo quirúrgico de 225 min y el sangrado de 274 ml, con un 13% de transfusión en el postoperatorio. De forma intraoperatoria se detectó la apertura de la pleura en 8 casos, de los cuales ninguno tuvo complicaciones mayores pulmonares durante el postoperatorio. Se produjeron 3 casos de derrame pleural leve en pacientes sin apertura de pleura, y un caso de hemoneumotórax por sangrado de vaso intercostal que requirió reintervención. El porcentaje de neuralgia intercostal fue del 3%. La estancia media hospitalaria fue de 6,7 días, y 24 de 31 pacientes pudieron iniciar movilización precoz el primer día postoperatorio.
El abordaje retropleural permite el tratamiento quirúrgico de patologías que requieren un acceso anterior a la columna toracolumbar, con un perfil bajo de complicaciones pulmonares y con las ventajas de las técnicas mínimamente invasivas en cuanto a menor sangrado, recuperación precoz y menos estancia hospitalaria. Su curva de aprendizaje es larga.
To review the complications associated with the minimally invasive retropleural approach used in the anterior approach to the thoraco-lumbar spine.
We present the MIS surgical technique and the evaluation of data collected prospectively from the initial series of 31 patients undergoing surgery. Pleural opening during the approach, lung complications derived, other surgical complications, time of intervention, intraoperative bleeding, need for transfusion and hospital stay are evaluated.
The mean age of the patients was 58 years, the surgical time 225 min, and the bleeding 274 ml, with a 13% postoperative transfusion. Intraoperatively, pleural opening was detected in 8 cases, of which none had major pulmonary complications during the postoperative period. There were 3 cases of mild pleural effusion, all patients without pleural opening, and one case of haemopneumothorax due to intercostal vessel bleeding that required reoperation. The percentage of intercostal neuralgia was 3%. The mean hospital stay was 6.7 days, and 24 of 31 patients were able to initiate early mobilization on the first postoperative day.
The retropleural approach allows the surgical treatment of pathologies requiring anterior access to the thoraco-lumbar spine, with a low profile of pulmonary complications, and with the advantages of minimally invasive techniques in terms of less bleeding, early recovery and shorter hospital stay. Nevertheless the learning curve is long.

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Clinical StudiesPulmonary complications in anterior-posterior thoracic lumbar fusions☆

Abstract

Background context

Purpose

Study design/setting

Patient sample

Outcome measures

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgements

Chest

Am J Surg

Am J Surg

Am J Med

Mayo Clin Proc

Chest

Chest

The diagnosis and prophylaxis of pulmonary complications of surgical operation

Br J Surg

Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery

J Gen Intern Med

Pulmonary function in asymptomatic adolescents with idiopathic scoliosis

Am Rev Respir Dis

Clinical Studies
Pulmonary complications in anterior-posterior thoracic lumbar fusions☆