Association Between Vitamin D Deficiency and Outcomes Following Spinal Fusion Surgery: A Systematic Review

doi:10.1016/j.wneu.2016.07.074

World Neurosurgery

Volume 95, November 2016, Pages 71-76

https://doi.org/10.1016/j.wneu.2016.07.074 Get rights and content

Background

Vitamin D deficiency is a relatively common occurrence in patients presenting for spinal surgery; however, whether this abnormality has any effect on spinal fusion outcomes remains unclear. We performed a systematic review of the available literature relevant to the association between vitamin D deficiency and spinal fusion outcomes.

Methods

We conducted a systematic and critical review of recent literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following databases were searched: MEDLINE/PubMed, Google Scholar, Cochrane, Web of Science, and Scopus. Key search terms were “vitamin D,” “spinal surgery outcomes,” “spinal fusion,” and “pseudarthrosis.” Papers included in the review were original research articles in peer-reviewed journals. The articles were thoroughly examined and compared on the basis of study design, outcomes, and results.

Results

A total of 5 studies were included in the qualitative analysis. In these studies, patients presenting with vitamin D deficiency achieved lower fusion rates and suffered higher rates of recurrent-persistent low back pain compared with patients with normal vitamin D levels. Studies examining the effect of postoperative vitamin D supplementation in deficient patients reported significant improvements in low back pain intensity, patient-reported outcomes scores, and fusion rates compared with baseline as well as with control groups.

Conclusions

The literature suggests that patients presenting for spinal fusion may benefit from correction of vitamin D deficiency to maximize the chance of a successful arthrodesis and to achieve optimal surgical outcomes. Future prospective studies are needed to determine whether routine preoperative treatment of this metabolic derangement is warranted.

Section snippets

Data Source and Search Strategy

We conducted this systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklists.¹² Data were collected from published articles from all available years. The databases queried for our electronic searches included MEDLINE/PubMed, Google Scholar, Cochrane, Web of Science, and Scopus. Various combinations of search key and Medical Subject Heading terms, including “vitamin D” AND “spinal fusion” OR “spinal surgery outcomes” OR

Search Results and Study Characteristics

Our initial search of MEDLINE/PubMed, Google Scholar, Cochrane, Web of Science, and Scopus yielded 296 pertinent articles. After a thorough review of the titles and abstracts, we identified 138 studies for possible inclusion. Studies were excluded for the following reasons: was an animal study; did not report on vitamin D status; was a case report, commentary, or letter to the editor; or did not include patients undergoing spinal fusion surgery. After excluding 133 studies (128 original

Discussion

The current literature suggests that vitamin D concentration is significantly associated with postoperative quality of life and functionality, as measured by ODI, EQ-5D, and JOA scores. Moreover, when postoperative supplementation was given to patients with vitamin D deficiency, improvements in low back pain intensity and mobilization were observed.15, 16, 17 More importantly, the fact that these conclusions were consistent in patient populations of different ethnic backgrounds strengthens

Conclusion

Surveys of current practice patterns have found that testing for serum vitamin D levels is not part of the routine preoperative laboratory evaluation of patient undergoing spinal fusion surgery.⁴⁷ As detailed in this review, recent evidence, although of very low quality, suggests that patients presenting for spinal fusion may benefit from correction of vitamin D deficiency to maximize the chance of successful arthrodesis and optimize postoperative functionality. Future studies hopefully will

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Lumbar spinal fusion surgery is a well-established treatment for various spinal disorders. However, one of its complications, pseudoarthrosis, poses a significant concern. This study aims to explore the incidence, time and predictive factors contributing to pseudoarthrosis in patients who have undergone lumbar fusion surgery over a 10-year period.
Data for this research was sourced from the PearlDiver database where insurance claims of patients who underwent multilevel lumbar spinal fusion between 01/01/2010 and 10/31/2022 were examined for claims of pseudoarthrosis within the 10 years of their index procedure. A variety of demographic, comorbid, and surgical factors were assessed, including age, gender, Elixhauser Comorbidity Index (ECI), surgical approach, substance use disorders and history of spinal disorders. Statistical analyses, including chi-squared tests, multivariate analysis, and cox survival analysis were employed to determine significant associations.
Among the 76,337 patients included in this retrospective study, 2.70% were diagnosed with symptomatic lumbar pseudoarthrosis at an average of 7.38 years in a 10-year follow-up. Multivariate and Cox hazard analyses revealed that significant predictors of symptomatic pseudoarthrosis development following multilevel primary lumbar fusion include vitamin D deficiency, osteoarthritis, opioid and NSAID use, tobacco use, and a prior history of congenital spine disorders.
In summary, this study revealed a 2.70% incidence of symptomatic lumbar pseudoarthrosis within 10 years of the index procedure. It highlighted several potential predictive factors, including comorbidities, surgical approaches, and substance use disorders, associated with the development of symptomatic pseudoarthrosis. Future research should focus on refining our understanding of these factors to improve patient outcomes and optimize healthcare resource allocation.
Is There a Correlation Between Preoperative or Postoperative Vitamin D Levels with Pseudarthrosis, Hardware Failure, and Revisions After Lumbar Spine Fusion?
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Vitamin D deficiency is a well-known cause of postoperative complications in patients undergoing orthopedic surgery. Orthopedic complications seen in vitamin D deficiency include nonunion, pseudarthrosis, and hardware failure. We seek to investigate the relationship between vitamin D deficiency and outcomes after lumbar spinal fusions.
A retrospective patient chart review was conducted at a single center for all patients who underwent lumbar spinal fusions from January 2015 to September 2017 with preoperative or postoperative vitamin D laboratory values. We recorded demographics, social history, medications, pre-existing medical conditions, bone density (dual-energy x-ray absorptiometry) T-scores, procedural details, 1-year postoperative Visual Analog Score (VAS), documented pseudarthrosis, revisions, and hardware failure. A total of 150 patients were initially included in the cohort for analysis.
Overall, preoperative and postoperative vitamin D levels were not significantly associated with a vast majority of the patient characteristics studied, including comorbidities, medications, or surgical diagnoses (P > 0.05). Age at surgery was significantly associated with vitamin D levels; older patients had higher serum levels of vitamin D both preoperatively (P = 0.03) and postoperatively (P = 0.01). Those with a higher average body mass index had lower vitamin D in both groups (P = 0.02). Vitamin D levels were not significantly associated with rates of postoperative pseudarthrosis, revision, or hardware complications (P > 0.05). VAS pain score at 1 year and smoking status preoperatively or postoperatively were not associated with vitamin D levels (P > 0.05).
Both preoperative and postoperative vitamin D levels were not significantly associated with an increased or decreased risk of pseudarthrosis, revision surgery, hardware failure, or 1-year VAS pain score after lumbar spine fusion surgery.
The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 2
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In total, one systematic review (Level II) and two observational studies (Level III) were included in this section. Kerezoudis and colleagues reviewed the literature to characterize an association between spinal fusion outcomes and preoperative serum vitamin D concentration values [49] and concluded that previously reported conflicting findings may be attributed to structural differences in vitamin D. For example, Schofferman et al. used a widely fluctuating 1,25-dihydroxy vitamin D3 (1,25-[OH]2D3) in their analysis of 41 patients who had undergone lumbar fusion and reported that vitamin D deficiency was not associated with higher rates of pseudoarthrosis [50]. Analysis in recent years has focused on a more stable form, V vitamin D, 25(OH)D.
Structured literature review.
To review the current literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery.
Application of lean methodology to health care involves standardization of work flow. Successful implementation of LEAN management can lead to dramatic reduction in variability and waste. Frailty, hemoglobin A1c (HbA1c) concentration, vitamin D level, mental health status, intraoperative fluid management (IFM), and tranexamic acid (TXA) administration may be modified to reduce complications after ASD surgery.
Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, Ovid, and Google Scholar databases were used to identify abstracts and citations for this review. Each topic was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). From 373 initial citations with abstract, 134 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 43 included studies.
We found fair evidence supporting an association between preoperative mental health disorders, frailty, vitamin D deficiency, and higher HbA1c levels and increased complications. Conversely, we found good evidence supporting an association between the use of intraoperative TXA and an optimized intraoperative fluid management and decreased complications.
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Observational cohort studies in the United States and internationally have demonstrated a high prevalence hypovitaminosis D in these patients [23–25]. Additionally, recent studies have demonstrated high rates of vitamin D insufficiency and deficiency in pediatric orthopaedic patients and adult patients undergoing foot and ankle, spine, joint replacement, and orthopaedic trauma surgeries [26,6,27–29]. Inkrott et al. retrospectively reviewed vitamin D levels in 218 patients undergoing shoulder arthroplasty and found that 43% of patients were vitamin D insufficient (< 30 ng/mL) and 11% were vitamin D deficient (< 20 ng/mL) [29].
Vitamin D plays an important role in the musculoskeletal system of the human body. Here, we review the most current literature on vitamin D as it relates to orthopaedic surgery and the musculoskeletal system, focusing largely on non-fracture applications.
A literature review was performed on the basic science of vitamin D metabolism, epidemiology of vitamin D levels, role of vitamin D within the musculoskeletal system, and the correlation of vitamin D with injuries and orthopaedic surgical outcomes.
The existing literature suggests vitamin D plays multiple roles in the musculoskeletal system. Recent research has shed light on the importance of vitamin D in the setting of soft tissue healing and recovery in addition to affecting postoperative outcomes after common orthopaedic procedures.
Given the widespread prevalence of vitamin D deficiency, orthopaedic surgeons should be aware of the current evidence regarding clinical implications in patients with musculoskeletal complaints.
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It remains one of the leading causes of revision surgery, accounting for 45–56% of cases.33–36 Multiple risk factors have been associated with the risk of developing pseudarthrosis, including obesity, chronic steroid use, smoking, malnutrition, poor surgical technique, as well as low bone mass and mineral density.4,30,37–39 Pseudarthrosis is asymptomatic in approximately 30% of cases.40–42
Osteoporosis is a relatively common finding in patients undergoing spine surgery. Osteoporosis increases the risk for complications secondary to implant or bone union failure, including proximal junctional failure and pseudarthrosis. In cases of severe symptoms or progressive deformity, pathology-driven revision surgery may be required. In general, posterior surgery is commonly advocated in cases of fixed deformity with additional osteotomies and decompressions as needed. Conversely, an anterior approach is typically reserved for cases with flexible deformity and anterior compressive structures. In these cases, the use of autograft is also recommended in order to facilitate bone osseo-integration.
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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Literature ReviewAssociation Between Vitamin D Deficiency and Outcomes Following Spinal Fusion Surgery: A Systematic Review

Background

Methods

Results

Conclusions

Section snippets

Data Source and Search Strategy

Search Results and Study Characteristics

Discussion

Conclusion

Am J Clin Nutr

Am J Clin Nutr

Mol Cell Endocrinol

World Neurosurg

Int J Surg

Nutr Res

Am J Clin Nutr

Ann Epidemiol

Mayo Clin Proc

Lancet

Orthop Clin North Am

Bone

Clin Biochem

Semin Arthritis Rheum

Bone

Bone

Spine J

Vitamin D: a millenium perspective

J Cell Biochem

Endocrinology: An Integrated Approach

Vitamin D deficiency

N Engl J Med

Vitamin D: photobiology, metabolism, mechanism of action, and clinical applications

Effectiveness and safety of vitamin D in relation to bone health

Evid Rep Technol Assess (Full Rep)

Vitamin D levels and 1-year fusion outcomes in elective spine surgery: a prospective observational study

Spine (Phila Pa 1976)

Literature Review
Association Between Vitamin D Deficiency and Outcomes Following Spinal Fusion Surgery: A Systematic Review