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Zhuo Xi, Shane Burch, Praveen V. Mummaneni, Rory Richard Mayer, Charles Eichler and Dean Chou

OBJECTIVE

Obese patients have been shown to have longer operative times and more complications from surgery. However, for obese patients undergoing minimally invasive surgery, these differences may not be as significant. In the lateral position, it is thought that obesity is less of an issue because gravity pulls the visceral fat away from the spine; however, this observation is primarily anecdotal and based on expert opinion. The authors performed oblique lumbar interbody fusion (OLIF) and they report on the perioperative morbidity in obese and nonobese patients.

METHODS

The authors conducted a retrospective review of patients who underwent OLIF performed by 3 spine surgeons and 1 vascular surgeon at the University of California, San Francisco, from 2013 to 2018. Data collected included demographic variables; approach-related factors such as operative time, blood loss, and expected temporary approach-related sequelae; and overall complications. Patients were categorized according to their body mass index (BMI). Obesity was defined as a BMI ≥ 30 kg/m2, and severe obesity was defined as a BMI ≥ 35 kg/m2.

RESULTS

There were 238 patients (95 males and 143 females). There were no significant differences between the obese and nonobese groups in terms of sex, levels fused, or smoking status. For the entire cohort, there was no difference in operative time, blood loss, or complications when comparing obese and nonobese patients. However, a subset analysis of the 77 multilevel OLIFs that included L5–S1 demonstrated that the operative times for the nonobese group was 223.55 ± 57.93 minutes, whereas it was 273.75 ± 90.07 minutes for the obese group (p = 0.004). In this subset, the expected approach-related sequela rate was 13.2% for the nonobese group, whereas it was 33.3% for the obese group (p = 0.039). However, the two groups had similar blood loss (p = 0.476) and complication rates (p = 0.876).

CONCLUSIONS

Obesity and morbid obesity generally do not increase the operative time, blood loss, approach-related sequelae, or complications following OLIF. However, obese patients who undergo multilevel OLIF that includes the L5–S1 level do have longer operative times or a higher rate of expected approach-related sequelae. Obesity should not be considered a contraindication to multilevel OLIF, but patients should be informed of potentially increased morbidity if the L5–S1 level is to be included.

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Zhuo Xi, Dean Chou, Praveen V. Mummaneni, Huibing Ruan, Charles Eichler, Chih-Chang Chang and Shane Burch

OBJECTIVE

In adult spinal deformity and degenerative conditions of the spine, interbody fusion to the sacrum often is performed to enhance arthrodesis, induce lordosis, and alleviate stenosis. Anterior lumbar interbody fusion (ALIF) has traditionally been performed, but minimally invasive oblique lumbar interbody fusion (OLIF) may or may not cause less morbidity because less retraction of the abdominal viscera is required. The authors evaluated whether there was a difference between the results of ALIF and OLIF in multilevel anterior or lateral interbody fusion to the sacrum.

METHODS

Patients from 2013 to 2018 who underwent multilevel ALIF or OLIF to the sacrum were retrospectively studied. Inclusion criteria were adult spinal deformity or degenerative pathology and multilevel ALIF or OLIF to the sacrum. Demographic, implant, perioperative, and radiographic variables were collected. Statistical calculations were performed for significant differences.

RESULTS

Data from a total of 127 patients were analyzed (66 OLIF patients and 61 ALIF patients). The mean follow-up times were 27.21 (ALIF) and 24.11 (OLIF) months. The mean surgical time was 251.48 minutes for ALIF patients and 234.48 minutes for OLIF patients (p = 0.154). The mean hospital stay was 7.79 days for ALIF patients and 7.02 days for OLIF patients (p = 0.159). The mean time to being able to eat solid food was 4.03 days for ALIF patients and 1.30 days for OLIF patients (p < 0.001). After excluding patients who had undergone L5–S1 posterior column osteotomy, 54 ALIF patients and 41 OLIF patients were analyzed for L5–S1 radiographic changes. The mean cage height was 14.94 mm for ALIF patients and 13.56 mm for OLIF patients (p = 0.001), and the mean cage lordosis was 15.87° in the ALIF group and 16.81° in the OLIF group (p = 0.278). The mean increases in anterior disc height were 7.34 mm and 4.72 mm for the ALIF and OLIF groups, respectively (p = 0.001), and the mean increases in posterior disc height were 3.35 mm and 1.24 mm (p < 0.001), respectively. The mean change in L5–S1 lordosis was 4.33° for ALIF patients and 4.59° for OLIF patients (p = 0.829).

CONCLUSIONS

Patients who underwent multilevel OLIF and ALIF to the sacrum had comparable operative times. OLIF was associated with a quicker ileus recovery and less blood loss. At L5–S1, ALIF allowed larger cages to be placed, resulting in a greater disc height change, but there was no significant difference in L5–S1 segmental lordosis.

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Michael M. Safaee, Alexander Tenorio, Joseph A. Osorio, Winward Choy, Dominic Amara, Lillian Lai, Serena S. Hu, Bobby Tay, Shane Burch, Sigurd H. Berven, Vedat Deviren, Sanjay S. Dhall, Dean Chou, Praveen V. Mummaneni, Charles M. Eichler, Christopher P. Ames and Aaron J. Clark

OBJECTIVE

Anterior lumbar interbody fusion (ALIF) is a powerful technique that provides wide access to the disc space and allows for large lordotic grafts. When used with posterior spinal fusion (PSF), the procedures are often staged within the same hospital admission. There are limited data on the perioperative risk profile of ALIF-first versus PSF-first circumferential fusions performed within the same hospital admission. In an effort to understand whether these procedures are associated with different perioperative complication profiles, the authors performed a retrospective review of their institutional experience in adult patients who had undergone circumferential lumbar fusions.

METHODS

The electronic medicals records of patients who had undergone ALIF and PSF on separate days within the same hospital admission at a single academic center were retrospectively analyzed. Patients carrying a diagnosis of tumor, infection, or traumatic fracture were excluded. Demographics, surgical characteristics, and perioperative complications were collected and assessed.

RESULTS

A total of 373 patients, 217 of them women (58.2%), met the inclusion criteria. The mean age of the study cohort was 60 years. Surgical indications were as follows: degenerative disease or spondylolisthesis, 171 (45.8%); adult deformity, 168 (45.0%); and pseudarthrosis, 34 (9.1%). The majority of patients underwent ALIF first (321 [86.1%]) with a mean time of 2.5 days between stages. The mean number of levels fused was 2.1 for ALIF and 6.8 for PSF. In a comparison of ALIF-first to PSF-first cases, there were no major differences in demographics or surgical characteristics. Rates of intraoperative complications including venous injury were not significantly different between the two groups. The rates of postoperative ileus (11.8% vs 5.8%, p = 0.194) and ALIF-related wound complications (9.0% vs 3.8%, p = 0.283) were slightly higher in the ALIF-first group, although the differences did not reach statistical significance. Rates of other perioperative complications were no different.

CONCLUSIONS

In patients undergoing staged circumferential fusion with ALIF and PSF, there was no statistically significant difference in the rate of perioperative complications when comparing ALIF-first to PSF-first surgeries.

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Michael M. Safaee, Alexander Tenorio, Joseph A. Osorio, Winward Choy, Dominic Amara, Lillian Lai, Annette M. Molinaro, Yalan Zhang, Serena S. Hu, Bobby Tay, Shane Burch, Sigurd H. Berven, Vedat Deviren, Sanjay S. Dhall, Dean Chou, Praveen V. Mummaneni, Charles M. Eichler, Christopher P. Ames and Aaron J. Clark

OBJECTIVE

Anterior approaches to the lumbar spine provide wide exposure that facilitates placement of large grafts with high fusion rates. There are limited data on the effects of obesity on perioperative complications.

METHODS

Data from consecutive patients undergoing anterior lumbar interbody fusion (ALIF) from 2007 to 2016 at a single academic center were analyzed. The primary outcome was any perioperative complication. Complications were divided into those occurring intraoperatively and those occurring postoperatively. Multivariate logistic regression was used to assess the association of obesity and other variables with these complications. An estimation table was used to identify a body mass index (BMI) threshold associated with increased risk of postoperative complication.

RESULTS

A total of 938 patients were identified, and the mean age was 57 years; 511 were females (54.5%). The mean BMI was 28.7 kg/m2, with 354 (37.7%) patients classified as obese (BMI ≥ 30 kg/m2). Forty patients (4.3%) underwent a lateral transthoracic approach, while the remaining 898 (95.7%) underwent a transabdominal retroperitoneal approach. Among patients undergoing transabdominal retroperitoneal ALIF, complication rates were higher for obese patients than for nonobese patients (37.0% vs 28.7%, p = 0.010), a difference that was driven primarily by postoperative complications (36.1% vs 26.0%, p = 0.001) rather than intraoperative complications (3.2% vs 4.3%, p = 0.416). Obese patients had higher rates of ileus (11.7% vs 7.2%, p = 0.020), wound complications (11.4% vs 3.4%, p < 0.001), and urinary tract infections (UTI) (5.0% vs 2.5%, p = 0.049). In a multivariate model, age, obesity, and number of ALIF levels fused were associated with an increased risk of postoperative complication. An estimation table including 19 candidate cut-points, odds ratios, and adjusted p values found a BMI ≥ 31 kg/m2 to have the highest association with postoperative complication (p = 0.012).

CONCLUSIONS

Obesity is associated with increased postoperative complications in ALIF, including ileus, wound complications, and UTI. ALIF is a safe and effective procedure. However, patients with a BMI ≥ 31 kg/m2 should be counseled on their increased risks and warrant careful preoperative medical optimization and close monitoring in the postoperative setting.