Obese Class III patients at significantly greater risk of multiple complications after lumbar surgery: an analysis of 10,387 patients in the ACS NSQIP database

Rafael A Buerba, Michael C Fu, Jordan A Gruskay, William D Long, Jonathan N Grauer
Spine Journal: Official Journal of the North American Spine Society 2014 September 1, 14 (9): 2008-18

BACKGROUND CONTEXT: Prior studies on the impact of obesity on spine surgery outcomes have focused mostly on lumbar fusions, do not examine lumbar discectomies or decompressions, and have shown mixed results regarding complications. Differences in sample sizes and body mass index (BMI) thresholds for the definition of the obese versus comparison cohorts could account for the inconsistencies in the literature.

PURPOSE: The purpose of the study was to analyze whether different degrees of obesity influence the complication rates in patients undergoing lumbar spine surgery.

STUDY DESIGN/SETTING: This was a retrospective cohort analysis of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2010.

PATIENT SAMPLE: Patients in the de-identified, risk-adjusted, and multi-institutional ACS NSQIP database undergoing lumbar anterior fusion, posterior fusion, transforaminal lumbar interbody fusion/posterior lumbar interbody fusion (TLIF/PLIF), discectomy, or decompression were included.

OUTCOME MEASURES: Primary outcome measures were 30-day postsurgical complications, including pulmonary embolism and deep vein thrombosis, death, system-specific complications (wound, pulmonary, urinary, central nervous system, and cardiac), septic complications, and having one or more complications overall. Secondary outcomes were time spent in the operating room, blood transfusions, length of stay, and reoperation within 30 days.

METHODS: Patients undergoing lumbar anterior fusion, posterior fusion, TLIF/PLIF, discectomy, or decompression in the ACS NSQIP, 2005 to 2010, were categorized into four BMI groups: nonobese (18.5-29.9 kg/m(2)), Obese I (30-34.9 kg/m(2)), Obese II (35-39.9 kg/m(2)), and Obese III (greater than or equal to 40 kg/m(2)). Obese I to III patients were compared with patients in the nonobese category using chi-square test and analysis of variance. Multivariate linear/logistic regression models were used to adjust for preoperative risk factors.

RESULTS: Data were available for 10,387 patients undergoing lumbar surgery. Of these, 4.5% underwent anterior fusion, 17.9% posterior fusion, 6.3% TLIF/PLIF, 40.7% discectomy, and 30.5% decompression. Among all patients, 25.6% were in the Obese I group, 11.5% Obese II, and 6.9% Obese III. On multivariate analysis, Obese I and III had a significantly increased risk of urinary complications, and Obese II and III patients had a significantly increased risk of wound complications. Only Obese III patients, however, had a statistically increased risk of having increased time spent in the operating room, an extended length of stay, pulmonary complications, and having one or more complications (all p<.05).

CONCLUSIONS: Patients with high BMI appear to have higher complication rates after lumbar surgery than patients who are nonobese. However, the complication rates seem to increase substantially for Obese III patients. These patients have longer times spent in the operating room, extended hospitals stays, and an increased risk for wound, urinary, and pulmonary complications and for having at least one or more complications overall. Surgeons should be aware of the increased risk of multiple complications for patients with BMI greater than or equal to 40 kg/m(2).

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