The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 85, Issue 11

Scientific Articles | November 01, 2003

Perioperative Complications of Posterior Lumbar Decompression and Arthrodesis in Older Adults

Leah Y. Carreon, MD¹; Rolando M. Puno, MD¹; John R. DimarII, MD¹; Steven D. Glassman, MD¹; John R. Johnson, MD¹

¹ Kenton D. Leatherman Spine Center, 210 East Gray Street, Suite 900, Louisville, KY 40202. E-mail address for L.Y. Carreon: lcarreon@spinemds.com

View Disclosures and Other Information

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Norton Healthcare. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. R.M.P., J.R.D. II, S.D.G., and J.R.J. acknowledge a financial relationship (consultants for and royalties from Medtronic Sofamore Danek), which may indirectly relate to the subject of this research.

Investigation performed at Norton Hospital, Louisville, Kentucky

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2003 Nov 01;85(11):2089-2092

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Abstract

Background: Lumbar arthrodesis is commonly done in elderly patients to treat degenerative spine problems. These patients may be at increased risk for complications because of their age and associated medical conditions. In this study, we examined the rates of perioperative complications associated with posterior lumbar decompression and arthrodesis in patients sixty-five years of age or older.

Methods: We reviewed the hospital records of ninety-eight patients who were sixty-five years of age or older when they had a posterior decompression and lumbar arthrodesis with instrumentation, between 1993 and 1995, to treat degenerative disease of the spine. The average age was seventy-two years (range, sixty-five to eighty-four years).

Results: Perioperative complications occurred in seventy-eight patients. Twenty-one patients had at least one major complication, and sixty-nine had at least one minor complication. Forty-nine patients had more than one complication. The most common major complication was wound infection (prevalence, 10%), and the most common minor complication was urinary tract infection (prevalence, 34%). The complication rate increased with older age, increased blood loss, longer operative time, and the number of levels of the arthrodesis.

Conclusions: Surgeons should be vigilant about perioperative complications in elderly patients treated with multi-level lumbar decompression and arthrodesis with instrumentation. Elderly patients should be made aware that they are at increased risk for surgical complications because of their age. Attention should be paid to controlling blood loss and limiting operative time.

Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Previous studies have shown that patients undergoing lumbar arthrodesis have substantially higher complication rates than do patients undergoing decompression alone¹. As the size of the geriatric population increases, the number of elderly patients presenting with painful degenerative disease of the lumbar spine requiring surgery is expected to increase concomitantly^2,3. Many patients require a posterior arthrodesis with instrumentation along with the decompression to treat the instability associated with degenerative spondylolisthesis, scoliosis, and spinal stenosis. However, we are not aware of any study that has addressed the perioperative complications occurring in elderly patients undergoing both decompression and arthrodesis of the lumbar spine.

The present study was undertaken to examine the rate of perioperative complications in patients treated with posterior lumbar decompression and arthrodesis at the age of sixty-five years or older. We also examined various patient-related and surgical variables and their relationship to the occurrence of perioperative complications.

Materials and Methods

Materials and Methods | Results | Discussion | References

From 1993 to 1995, 101 patients who were sixty-five years of age or older had a posterior decompression and lumbar arthrodesis with instrumentation for the treatment of degenerative disease of the spine at Norton Hospital, Louisville, Kentucky. All patients were managed with pedicle screw instrumentation and autogenous iliac-crest bone-grafting. All operations were done by attending physicians assisted by spine fellows. Complete hospital records on ninety-eight patients were available for review. The indications for surgery were lumbar spinal stenosis requiring wide decompression causing instability, and spondylolisthesis and degenerative scoliosis in patients with incapacitating back and lower-limb pain that was unresponsive to nonoperative management. We excluded all patients who had a neoplasm, osteomyelitis, a spinal abscess, or a fracture-dislocation; those who had had a previous decompression and arthrodesis; those who were treated with an anterior interbody arthrodesis; and those who had an unrelated elective second major operation during the same hospitalization.

Hospital records, including operative notes, progress notes, and discharge summaries, were abstracted by a single observer who had no involvement with the patient's care. The records were reviewed to determine demographic data, the primary diagnosis, and preoperative comorbidities. Comorbidities were classified as pulmonary, cardiac, metabolic, or miscellaneous. Operative records were reviewed to document the number of disc levels fused, blood loss, operative time, and complications.

Postoperative management included early walking and removal of indwelling catheters from men on the second postoperative day. Catheters were removed from women once they were able to walk independently to the bathroom. Dressings were changed on the second postoperative day, and closed suction drains were removed when their output was less than 30 mL in eight hours. The hemoglobin level was checked daily for three consecutive postoperative days. Incentive spirometry was used by all patients. All patients wore compressive stockings and used sequential compressive devices for prophylaxis against deep vein thrombosis. Anticoagulation therapy with Lovenox (enoxaparin) was used only for patients at high risk for the development of deep vein thrombosis, such as those who were obese, used estrogen, or had a history of myocardial infarction or cardiac arrhythmias.

Postoperative records were reviewed for complications, the need for transfusion, and the length of the hospital stay. Complications were defined as any event for which the patient required a specific intervention or treatment. All medical and surgical complications related to the posterior spinal decompression and arthrodesis were recorded. Complications that occurred after discharge, such as failure of the instrumentation and nonunion, were excluded. The complications were categorized as pulmonary, gastrointestinal, wound-related, hematologic, operative, neurologic, cardiac, renal, and miscellaneous. They were further categorized as major or minor. A complication that adversely affected the recovery of the patient was considered a major complication. A complication that was noted in the medical records but did not alter the patient's recovery was considered a minor complication.

There were thirty-three men and sixty-five women. The average age at the time of the surgery was seventy-two years (range, sixty-five to eighty-four years). The average duration of the hospitalization was 9.7 days (range, four to thirty-two days). Eighty-six (88%) of the ninety-eight patients had preoperative comorbidities requiring medical intervention (Table I). The most common surgical indication was spinal stenosis requiring wide decompression (Table II). Since degenerative spondylolisthesis and scoliosis may also cause spinal stenosis, these diagnoses may have overlapped.

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TABLE I Preoperative Comorbidities in the Ninety-eight Patients

Comorbidities	No.
Hypertension	55 (56%)
Coronary artery disease	12 (12%)
Peptic ulcer disease	11 (11%)
Diabetes mellitus	10 (10%)
Insulin-dependent	4 (4%)
Non-insulin-dependent	6 (6%)
Hypothyroid disease	9 (9%)
Chronic obstructive pulmonary disease	8 (8%)
Asthma	7 (7%)
Cholecystitis	7 (7%)
Diverticulitis	6 (6%)
Carcinoma in remission	6 (6%)
Arrhythmias	3 (3%)

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TABLE I Preoperative Comorbidities in the Ninety-eight Patients

Comorbidities	No.
Hypertension	55 (56%)
Coronary artery disease	12 (12%)
Peptic ulcer disease	11 (11%)
Diabetes mellitus	10 (10%)
Insulin-dependent	4 (4%)
Non-insulin-dependent	6 (6%)
Hypothyroid disease	9 (9%)
Chronic obstructive pulmonary disease	8 (8%)
Asthma	7 (7%)
Cholecystitis	7 (7%)
Diverticulitis	6 (6%)
Carcinoma in remission	6 (6%)
Arrhythmias	3 (3%)

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TABLE II Surgical Indications in the Ninety-eight Patients

Diagnosis	No.
Spinal stenosis	93 (95%)
Spondylolisthesis	38 (39%)
Scoliosis	13 (13%)

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TABLE II Surgical Indications in the Ninety-eight Patients

Diagnosis	No.
Spinal stenosis	93 (95%)
Spondylolisthesis	38 (39%)
Scoliosis	13 (13%)

Statistical Methods

Logistic regression analysis was performed with the SAS statistical program (SAS Institute, Cary, North Carolina) to test whether age, primary diagnosis, presence of preoperative comorbidities, and operative procedure were independently associated with morbidity or mortality.

Results

Materials and Methods | Results | Discussion | References

An average of 2.4 levels (range, one to five levels) was treated with decompression, arthrodesis, and instrumentation. The average estimated blood loss was 679.1 mL (range, 300 to 800 mL), and the average operative time was 4.9 hours (range, 1.5 to 8.8 hours). No major intraoperative complication was noted. A dural tear was reported in five procedures. Patients who were seventy-five years of age or older had a longer average hospital stay (Table III), but this increase was not significant (p = 0.43).

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TABLE III Complications in the Ninety-eight Patients

Age (yr)	Major Complication*	Minor Complication*	Hospitalization Prolonged*	Mean Hospital Stay (days)
65-69	14 (14.3%)	81 (82.7%)	31 (31.6%)	9.3
70-74	13 (13.3%)	75 (76.5%)	26 (26.5%)	8.9
=75	48 (49.0%)	77 (78.6%)	49 (50.0%)	10.9

The values are given as the number of patients, with the percentage in parentheses

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TABLE III Complications in the Ninety-eight Patients

Age (yr)	Major Complication*	Minor Complication*	Hospitalization Prolonged*	Mean Hospital Stay (days)
65-69	14 (14.3%)	81 (82.7%)	31 (31.6%)	9.3
70-74	13 (13.3%)	75 (76.5%)	26 (26.5%)	8.9
=75	48 (49.0%)	77 (78.6%)	49 (50.0%)	10.9

The values are given as the number of patients, with the percentage in parentheses

Perioperative complications occurred in seventy-eight patients (Table III). Twenty-one patients (21%) had at least one major complication, sixty-nine (70%) had at least one minor complication, and forty-nine (50%) had more than one complication. Two (2%) of the patients died.

The most common major complication was wound infection (Table IV). All infections were treated with incision, débridement, and placement of antibiotic-impregnated beads⁴. The most common minor complication was urinary tract infection (Table V).

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TABLE IV Major Complications in the Ninety-eight Patients

Major Complication	No.
Wound infection	10 (10%)
Pneumonia	5 (5%)
Renal failure	5 (5%)
Myocardial infarction	3 (3%)
Respiratory distress	2 (2%)
Neurologic deficit	2 (2%)
Congestive heart failure	2 (2%)
Cerebrovascular accident	1 (1%)

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TABLE IV Major Complications in the Ninety-eight Patients

Major Complication	No.
Wound infection	10 (10%)
Pneumonia	5 (5%)
Renal failure	5 (5%)
Myocardial infarction	3 (3%)
Respiratory distress	2 (2%)
Neurologic deficit	2 (2%)
Congestive heart failure	2 (2%)
Cerebrovascular accident	1 (1%)

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TABLE V Minor Complications in the Ninety-eight Patients

Minor Complication	No.
Urinary tract infection	33 (34%)
Anemia requiring transfusion	26 (27%)
Confusion	26 (27%)
Ileus	22 (22%)
Arrhythmias	7 (7%)
Transient hypoxia	7 (7%)
Wound seroma	5 (5%)
Leg dysesthesia	2 (2%)

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TABLE V Minor Complications in the Ninety-eight Patients

Minor Complication	No.
Urinary tract infection	33 (34%)
Anemia requiring transfusion	26 (27%)
Confusion	26 (27%)
Ileus	22 (22%)
Arrhythmias	7 (7%)
Transient hypoxia	7 (7%)
Wound seroma	5 (5%)
Leg dysesthesia	2 (2%)

With the numbers available, the presence, type, or number of comorbidities was not associated with the length of the hospital stay or with the prevalence of any major or minor complication (p = 0.05). Neither the type nor the number of spine diagnoses influenced the prevalence of any major or minor complication (p = 0.04).

Logistic regression analysis showed that the amount of blood loss and the operative time were related to the number of levels fused (p < 0.001). It also showed that the length of the hospital stay was influenced by the patient's age, with patients seventy-five years of age or older requiring more days in the hospital. The prevalence of complications (major or minor) was affected by the number of levels fused, with an odds ratio of 2.40 with each increase in the number of levels fused. The prevalence of minor complications was similarly influenced by the number of levels fused, with an odds ratio of 1.53 with each increase in the number of levels fused. The prevalence of major complications was influenced by the patient's age (odds ratio, 1.15), the number of levels fused (odds ratio, 2.06), and the amount of blood loss during the surgery (odds ratio, 1.01). With the numbers available, the primary diagnosis, the presence of preoperative medical disease, and the operative time were not significantly associated with the length of hospital stay (p = 0.03) or the occurrence of a complication (p = 0.04). The presence of preoperative diabetes mellitus, either insulin or non-insulin-dependent, was not associated with an increased risk of infection, with the numbers available.

The two deaths in the series were both from postoperative wound sepsis. One man died at the age of seventy-one years, and another man died at the age of eighty-one years.

Discussion

Materials and Methods | Results | Discussion | References

An increasing number of elderly patients are undergoing posterolateral arthrodesis of the lumbar spine with instrumentation for the treatment of degenerative disorders¹. Previous studies have shown higher rates of morbidity and mortality among older patients undergoing discectomies⁵. Some studies have shown that other operative procedures on the lumbar spine are associated with greater morbidity than are discectomies^1,6,7. However, there is little documentation of the specific types and frequencies of the complications associated with posterolateral lumbar decompression and arthrodesis.

The overall complication rate in our series was 80% (seventy-eight of ninety-eight patients). At least one major complication occurred in twenty-one patients, and at least one minor complication occurred in sixty-nine. However, these values may underestimate the complications that actually occurred since it is likely that not all minor complications were recorded. Smith and Hanigan found that twenty-six of seventy-eight patients who had undergone decompressive lumbar surgery when they were older than seventy years of age had complications⁸. Benz et al. showed that thirty-two (41%) of seventy-eight patients who had had a decompression or arthrodesis of the lumbar spine when they were older than seventy years of age had a complication².

In the present study, older age and the number of levels fused were identified as risk factors for the development of a complication. It appears that elderly patients are less able to tolerate major surgery because of their general medical condition and associated medical problems.

A greater number of fused levels was associated with greater intraoperative blood loss, longer operative time, and a higher prevalence of major complications. Adding an arthrodesis to the decompression increases the operative time and blood loss because of the necessity of obtaining a bone graft. The presence, type, or number of preoperative medical conditions was not related to the prevalence of complications. However, eighty-six (88%) of the ninety-eight patients had a concurrent medical disease. This finding is similar to that of Benz et al.², who reported that the presence of associated medical diseases did not affect the frequency of postoperative complications. However, other studies^8,9 showed that the prevalence of postoperative morbidity increased as the number of premorbid diseases increased. We did not find an association between the primary spinal diagnosis and the occurrence of a complication. In a study by Deyo et al.³, patients with spinal stenosis were at the highest risk for complications, but those patients also tended to be older. This increased risk was not reflected in our study since ninety-three (95%) of the ninety-eight patients had spinal stenosis and all of the patients were elderly. Patients with diabetes did not have a higher rate of wound infection in our study, but there were too few such patients for us to make a firm conclusion. Bendo et al.¹⁰, in a review of the cases of thirty patients with diabetes who had undergone lumbar arthrodesis, also found no increase in the complication rate.

The limitations of our study are its retrospective design, the small number of patients, and the lack of a cost analysis.

Surgeons should be vigilant about perioperative complications in patients of advanced age who are treated with multiple-level lumbar decompression and arthrodesis with instrumentation. Attention should be paid to the control of blood loss and limitation of operative time.

References

Materials and Methods | Results | Discussion | References

Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ. Lumbar spine fusion. A cohort study of complications, reoperations, and resource use in the Medicare population. Spine.1993;18: 1463-70.181463 1993 [PubMed]

Benz RJ, Ibrahim ZG, Afshar P, Garfin SR. Predicting complications in elderly patients undergoing lumbar decompression. Clin Orthop.2001;384: 116-21.384116 2001 [PubMed][CrossRef]

Deyo RA, Cherkin DC, Loeser JD, Bigos SJ, Ciol MA. Morbidity and mortality in association with operations on the lumbar spine. The influence of age, diagnosis, and procedure. J Bone Joint Surg Am.1992;74: 536-43.74536 1992

Glassman SD, Dimar JR, Puno RM, Johnson JR. Salvage of instrumented lumbar fusions complicated by surgical wound infection. Spine.1996;21: 2163-9.212163 1996 [PubMed][CrossRef]

Stolke D, Sollmann WP, Seifert V. Intra- and postoperative complications in lumbar disc surgery. Spine.1989;14: 56-9.1456 1989 [PubMed][CrossRef]

Deyo RA, Cherkin D, Conrad D, Volinn E. Cost, controversy, crisis: low back pain and the health of the public. Annu Rev Public Health.1991;12: 141-56.12141 1991 [PubMed][CrossRef]

Waddell G, Kummel EG, Lotto WN, Graham JD, Hall H, McCulloch JA. Failed lumbar disc surgery and repeat surgery following industrial injuries. J Bone Joint Surg Am.1979;61: 201-7.61201 1979

Smith EB, Hanigan WC. Surgical results and complications in elderly patients with benign lesions of the spinal canal. J Am Geriatr Soc.1992;40: 867-70.40867 1992 [PubMed]

Oldridge NB, Yuan Z, Stoll JE, Rimm AR. Lumbar spine surgery and mortality among Medicare beneficiaries, 1986. Am J Public Health.1994;84: 1292-8.841292 1994 [PubMed][CrossRef]

Bendo JA, Spivak J, Moskovich R, Neuwirth M. Instrumented posterior arthrodesis of the lumbar spine in patients with diabetes mellitus. Am J Orthop.2000;29: 617-20.29617 2000 [PubMed]

Topics

hemorrhage ; surgical complications ; decompression, external ; arthrodesis ; lumbar spine decompression

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Leah Y. Carreon, Rolando M. Puno, John R. DimarII, Steven D. Glassman, John R. Johnson; Perioperative Complications of Posterior Lumbar Decompression and Arthrodesis in Older Adults. The Journal of Bone & Joint Surgery. 2003 Nov;85(11):2089-2092.

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