Impact of obesity on complications, infection, and patient-reported outcomes in adult spinal deformity surgery

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OBJECT

Adult spinal deformity (ASD) surgery is known for its high complication rate. This study examined the impact of obesity on complication rates, infection, and patient-reported outcomes in patients undergoing surgery for ASD.

METHODS

This study was a retrospective review of a multicenter prospective database of patients with ASD who were treated surgically. Patients with available 2-year follow-up data were included. Obesity was defined as having a body mass index (BMI) ≥ 30 kg/m2. Data collected included complications (total, minor, major, implant-related, radiographic, infection, revision surgery, and neurological injury), estimated blood loss (EBL), operating room (OR) time, length of stay (LOS), and patient-reported questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], and Scoliosis Research Society [SRS]) at baseline and at 6 weeks, 1 year, and 2 years postoperatively. The impact of obesity was studied using multivariate modeling, accounting for confounders.

RESULTS

Of 241 patients who satisfied inclusion criteria, 175 patients were nonobese and 66 were obese. Regression models showed that obese patients had a higher overall incidence of major complications (IRR 1.54, p = 0.02) and wound infections (odds ratio 4.88, p = 0.02). Obesity did not increase the number of minor complications (p = 0.62), radiographic complications (p = 0.62), neurological complications (p = 0.861), or need for revision surgery (p = 0.846). Obesity was not significantly correlated with OR time (p = 0.23), LOS (p = 0.9), or EBL (p = 0.98). Both groups experienced significant improvement overtime, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001).

CONCLUSIONS

This study revealed that obese patients have an increased risk of complications following ASD correction. Despite these increased complications, obese patients do benefit from surgical intervention; however, their improvement in health-related quality of life (HRQL) is less than that of nonobese patients.

ABBREVIATIONSASD = adult spinal deformity; BMI = body mass index; CCI = Charlson Comorbidity Index; EBL = estimated blood loss; HRQL = health-related quality of life; IBF = interbody fusion; IRR = incidence rate ratio; LOS = length of stay; ODI = Oswestry Disability Index; OR = operating room; SF = Short Form; SRS = Scoliosis Research Society.

Abstract

OBJECT

Adult spinal deformity (ASD) surgery is known for its high complication rate. This study examined the impact of obesity on complication rates, infection, and patient-reported outcomes in patients undergoing surgery for ASD.

METHODS

This study was a retrospective review of a multicenter prospective database of patients with ASD who were treated surgically. Patients with available 2-year follow-up data were included. Obesity was defined as having a body mass index (BMI) ≥ 30 kg/m2. Data collected included complications (total, minor, major, implant-related, radiographic, infection, revision surgery, and neurological injury), estimated blood loss (EBL), operating room (OR) time, length of stay (LOS), and patient-reported questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], and Scoliosis Research Society [SRS]) at baseline and at 6 weeks, 1 year, and 2 years postoperatively. The impact of obesity was studied using multivariate modeling, accounting for confounders.

RESULTS

Of 241 patients who satisfied inclusion criteria, 175 patients were nonobese and 66 were obese. Regression models showed that obese patients had a higher overall incidence of major complications (IRR 1.54, p = 0.02) and wound infections (odds ratio 4.88, p = 0.02). Obesity did not increase the number of minor complications (p = 0.62), radiographic complications (p = 0.62), neurological complications (p = 0.861), or need for revision surgery (p = 0.846). Obesity was not significantly correlated with OR time (p = 0.23), LOS (p = 0.9), or EBL (p = 0.98). Both groups experienced significant improvement overtime, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001).

CONCLUSIONS

This study revealed that obese patients have an increased risk of complications following ASD correction. Despite these increased complications, obese patients do benefit from surgical intervention; however, their improvement in health-related quality of life (HRQL) is less than that of nonobese patients.

In 2011, a publication by Finucane et al.20 reported that the worldwide population had gained 0.4–0.5 kg/m2 per decade since 1980. The obese (body mass index [BMI] ≥ 30 kg/m2) and overweight (BMI ≥ 25 kg/m2) populations are increasing worldwide, with 4 of 10 adults classified as overweight or obese in 2013, according to the Global Burden of Disease Study.44 Obesity is particularly prevalent in the US, where 31.7% of adult men and 33.9% of adult women are classified as obese, accounting for a total of 13% of the global obese population; this number is expected to increase.

Adult spinal deformity (ASD) is common, and its incidence increases with age. The prevalence of ASD in the elderly population has been investigated, with Schwab et al.56 reporting rates of ASD up to 68% in patients over the age of 65 years.

Regarding ASD treatment, multiple reports have documented the superiority of surgical intervention and its potential ability to improve pain and disability, the 2 primary presenting complaints of patients with ASD.5,23,61,62 However, several authors have identified high complication rates following ASD surgery,3,12,13,27,39,57,63,68 with complication rates as high as 95%.39

Several studies have examined the impact of obesity on the surgical treatment of spinal pathologies and reported increased surgical-site infections for obese patients in the context of elective lumbar spinal fusion for degenerative conditions.15,47 When looking at overall complications in the context of lumbar and cervical spine surgery, the effect of obesity is more controversial. Whereas some authors have associated obesity with increased complication rates,6,32,33,40,58,59 others failed to detect a link between BMI and postoperative morbidity.45,65,75 Similarly, there is no consensus on the impact of BMI on patient-reported outcomes. Several authors have reported inferior postoperative outcomes in obese patients undergoing elective degenerative lumbar, cervical, and deformity surgery,2,34,76 whereas others did not find that obesity negatively impacts measures of health-related quality of life (HRQL).15,26,53,70 In the spinal deformity literature, a publication by Smith et al. identified high BMI as a risk factor for worse postoperative outcomes in both older and younger ASD patients undergoing surgical treatment.64 Recently, a subgroup analysis of the Spine Patient Outcomes Research Trial (SPORT)51 concluded that obese patients with degenerative spondylolisthesis and spinal stenosis experienced similar postoperative improvement compared with nonobese patients. However, nonoperatively treated obese patients reported significantly worse outcomes than nonobese patients. The majority of the body of evidence on the impact of obesity on complications and outcomes in spinal surgery focuses on specific spinal pathologies such as elective lumbar degenerative conditions, spinal stenosis, and cervical-spine deformities. Thus, the clinical relevance of obesity in the context of ASD surgery has not been well defined.

In the present study, our objective was to investigate the impact of obesity on complications, infection, and patient-reported outcomes for adults with spinal deformity undergoing surgical treatment.

Methods

Database

A multiinstitutional prospective database of consecutively enrolled ASD patients was queried to obtain the data. This database included patients enrolled at 11 institutions across the US, each with a high volume of ASD surgery (> 100 cases performed annually). Institutional review board approval was obtained at all participating centers. Inclusion criteria for the database were: age > 18 years, presence of spinal deformity as defined by scoliosis Cobb angle ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, pelvic tilt ≥ 25°, and/or thoracic kyphosis (TK) ≥ 60°. Exclusion criteria included spinal deformity of a neuromuscular etiology and presence of active infection or malignancy.

Data Collection

In addition to the aforementioned inclusion criteria for the database, the present study only included the patients with complete HRQL and clinical data at baseline and 2-year follow-up. Patients without recorded baseline BMI were excluded. Specifically, the following demographic and clinical data were obtained for each patient: age, sex, BMI, Charlson Comorbidity Index (CCI) score,9 smoking status, comorbidities, and surgical history. Surgical data collected included surgical approach, osteotomies performed, levels fused, operating room time (OR time), estimated blood loss (EBL), use of interbody fusion (IBF) or decompression, and length of hospital stay (LOS).

Obesity was defined as a BMI ≥ 30 kg/m2 (http://www.cdc.gov/obesity/adult/defining.html). The incidence of specific complications related to the index procedure was evaluated (Table 1) and the timing of the complications was recorded. Complications were categorized as major and minor according to criteria previously reported.27 Standardized HRQL measures included the Oswestry Disability Index (ODI),17 Scoliosis Research Society-22 (SRS-22),4 and Short Form-36 (SF-36)72 questionnaires and were collected at baseline and at 6 weeks, 1 year, and 2 years after surgery.

TABLE 1.

Complications checklist for patients undergoing ASD surgery

ComplicationsMajorMinor
InfectionDeep

Pneumonia

Sepsis
Superficial

Urinary tract infection

Clostridium difficile
ImplantHook dislodgement

Interbody fracture

Interbody migration

Rod fracture

Rod dislodgement

Screw fracture
Painful implants

Prominence

Screw malposition

Interbody subsidence

Crosslink dislodgement

Set screw dislodgement

Screw-bone interface loosening
NeurologicalVisual deficit/blindness

Brachial plexus injury

Cerebrovascular accident/stroke

Spinal cord injury with incomplete deficit

Spinal cord injury with complete deficit

Nerve root injury with weakness

Retrograde ejaculation

Bowel/bladder deficit
Neuropathy or sensory deficit

Pain (radiculopathy)

Peripheral nerve palsy

Delirium
CardiopulmonaryCardiac arrest

Pulmonary embolism

Respiratory arrest

Deep vein thrombosis

Congestive heart failure

Myocardial infarction

Reintubation

Acute respiratory distress syndrome
Coagulopathy

Arrhythmia

Pleural effusion

Pneumothorax
GastrointestinalObstruction

Perforation

Bleed requiring surgery

Pancreatitis requiring surgery

Cholecystitis requiring surgery

Liver failure

Superior mesenteric artery syndrome
Ileus

Bleed not requiring surgery

Pancreatitis not requiring surgery

Cholecystitis not requiring surgery
RadiographicDJK (requiring surgery)

PJK (requiring surgery)

Pseudarth rosis
DJK (not requiring surgery)

PJK (not requiring surgery)

Coronal imbalance

Curve decompensation

Heterotopic ossification

Sagittal imbalance

Adjacent-segment degeneration
RenalAcute renal failure requiring dialysisAcute renal failure requiring medical intervention
Wound problemsDehiscence requiring surgery

Hematoma/seroma with neurological deficit

Hematoma/seroma, no neurological deficit requiring

surgery

Incisional hernia
Hematoma/seroma not requiring surgery

Hernia

Dehiscence not requiring surgery

OperativeRetained sponge/instrument

Wrong surgical level

Unintended extension of fusion

Vascular injury

Visceral injury

EBL >4 L
Dural tear

Fixation failure (hook/screw)

Implant failure

Pedicle fracture

Posterior element fracture

Vertebral body fracture
VascularVascular injuryCoagulopathy

Thrombophlebitis
MortalityAll major

DJK = distal junctional kyphosis; PJK = proximal junctional kyphosis.

Statistical Analysis

Statistical analysis was performed using Stata v13 (StataCorp.). Univariate testing was performed using Student t-tests or chi-square tests as appropriate. The correlation of obesity and complications (major, minor, overall, radiographic, implant-related, revision surgery, neurological, and wound infection) was examined using multivariate Poisson or logistic regression modeling as appropriate. The impact of obesity on perioperative data (EBL, LOS, and OR time) was examined using multivariate linear regression. The effect of obesity on HRQL measures (SRS-22, ODI, and SF-36 scores) was determined using multivariate repeated-measures mixed models. All models accounted for potential confounders as determined by univariate analysis and expert opinion. The level of significance was p < 0.05.

Results

Demographic and Operative Data

A total of 286 patients in the database were eligible for 2-year follow-up, of which 45 patients were excluded from the study due to absence of baseline BMI data (n = 17) and incomplete HRQL data (n = 28). A total of 241 patients met inclusion criteria (175 nonobese, 66 obese). Baseline characteristics and perioperative data for obese and nonobese patients were compared (Table 2). Patients in the obese group had an average BMI of 36.05 kg/m2 versus 24.24 kg/m2 for the nonobese (p < 0.0001). Compared with nonobese patients, the obese group was, on average, older (mean age of 59.8 years vs 53.6 years, p = 0.0038), had more baseline comorbidities (mean CCI of 2.01 vs 1.19, p = 0.0002), had a higher incidence of previous spine surgery (55.4% vs 38.1%, p = 0.017), and a lower incidence of smoking (3.1% vs 11.7%, p = 0.048). The 2 groups were similar with regard to sex distribution (p = 0.46).

TABLE 2.

Comparison of baseline demographic data and surgical magnitude between obese and nonobese patients

VariableNonobeseObesep Value
No. of patients17566
Baseline patient factors
 BMI (kg/m2)24.236.1<0.0001
 Sex (F)86.7%83.1%0.46
 Age (yrs)53.659.80.0038
 Previous spine surgery38.1%55.4%0.017
 CCI1.192.010.0002
 Smoker11.7%3.1%0.048
Magnitude of surgery
 Major osteotomy15.4%27.3%0.035
 Levels9.549.420.8
 Posterior-only approach61.1%62.1%0.34
 IBF51.4%59.1%0.288
 Decompression49.1%72.7%0.001

When comparing the magnitude of surgery between the 2 groups, obese patients had a higher incidence of major (3-column) osteotomies (27.3% vs 15.4%, p = 0.035) and decompression performed (72.7% vs 49.1%, p = 0.001). There were no statistically significant differences between the 2 groups with regard to the number of levels fused (p = 0.8), the incidence of IBF (p = 0.288), and the surgical approach (p = 0.34) (Table 2).

The differences between the 2 groups in regard to demographic data and magnitude of surgery were accounted for in all subsequent analysis through multivariate modeling.

Complications

Overall, a total of 167 patients sustained at least 1 complication (69% overall rate, 65% for nonobese patients, and 78.8% for obese patients), with 94 patients (39% overall rate, 33.7% for nonobese patients, and 53% for obese patients) sustaining at least 1 major complication and 118 patients (49% overall rate, 46.3% for nonobese patients, and 56% for obese patients) sustaining at least 1 minor complication. The impact of obesity on overall, major, and minor complications was analyzed using multivariate Poisson regression, adjusting for the following confounders: age, smoking status, comorbidities, previous spine surgery, and magnitude of surgery (osteotomy, decompression). The results showed that obese patients had a higher rate of major complications (incidence rate ratio [IRR] 1.54, p = 0.021, a trend toward higher overall complications (IRR 1.26, p = 0.054), and a similar rate of minor complications (p = 0.62) (Table 3).

TABLE 3.

Multivariate poisson regression results showing the IRR of overall, major, and minor complications in obese patients*

Complications, 2 YrsIRRp Value
Overall1.260.054
Major1.540.021
Minor1.080.62

Complications in patients with BMI ≥ 30. All models accounted forage, smoking status, comorbidities, previous spine surgery, and magnitude of surgery.

Individual Complications

Based on the entire study population, the infection rate was 5.4% (3.4% nonobese patients, 10.6% obese patients), and 20.7% of patients (18.8% nonobese patients, 25.75% obese patients) sustained at least 1 radiographic complication, 16% of patients (14.3% nonobese patients, 21.2% obese patients) had at least 1 implant-related complication, and 20.3% of patients (19.4% nonobese patients, 22.7% obese patients) had at least 1 neurological complication. The overall 2-year surgical revision rate was 20.7% (20% nonobese patients, 22.7% obese patients). The effect of obesity on specific types of complications was assessed using multivariate Poisson and logistic regression to adjust for potential confounders. This analysis demonstrated that obesity was an independent risk factor for postoperative wound infection (odds ratio 4.88, p = 0.02). However, obesity was not associated with a significantly increased risk of neurological complications (p = 0.88), revision surgery (p = 0.84), or radiographic complications (p = 0.62). Absolute weight (odds ratio 1.16, p = 0.064), rather than BMI (p = 0.80), showed a trend toward an increased risk of implant-related complications (Table 4).

TABLE 4.

Multivariate poisson and logistic regression showing the IRR and odds ratio of specific complications in obese patients*

Complications, 2 YrsIRR/Odds Ratiop Value
Neurological0.030.881
Radiographic−0.1390.626
Revision surgery1.070.846
Infection4.880.02
Implant (BMI)0.080.804
Implant (weight)1.160.064

All models accounted for age, smoking status, comorbidities, previous spine surgery, and magnitude of surgery. Radiographic complications, implant-related complications, and revision surgeries also accounted for rod size and rod material.

Operative Data

To study the impact of obesity on operative data, multivariate linear regression modeling was performed, accounting for potential confounders. Results revealed that obesity did not significantly increase average LOS (p = 0.9), average EBL (p = 0.98), or average OR time (p = 0.23) (Table 5).

TABLE 5.

Multivariate linear regression results looking at EBL, OR time, and LOS*

2-Yr OnlyCoefficientp Value
LOS0.050.9
EBL5.990.98
OR time23.20.23

All models accounted for age, smoking status, comorbidities, previous spine surgery, and magnitude of surgery.

Patient-Reported Outcomes

The impact of obesity on HRQL was assessed using multivariate repeated-measures mixed models. Models accounted for age, comorbidities, magnitude of surgery, and major complications including revision surgeries. These analyses demonstrated that both obese and nonobese patients experienced significant improvement in their HRQL over time, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001) (Table 6, Figs. 13).

FIG. 1.
FIG. 1.

Results of multivariate repeated-measures mixed models show the difference between SF-36 physical scores in obese versus nonobese groups at baseline and at 6-week, 1-year, and 2-year follow-up. Figure is available in color online only.

FIG. 2.
FIG. 2.

Results of multivariate repeated-measures mixed models show the difference between ODI scores in obese versus nonobese groups at baseline and at 6-week, 1-year, and 2-year follow-up. Figure is available in color online only.

FIG. 3.
FIG. 3.

Results of multivariate repeated-measures mixed models show the difference between SRS scores in obese versus nonobese groups at baseline and at 6-week, 1-year, and 2-year follow-up. Figure is available in color online only.

TABLE 6.

Multivariate repeated-measures mixed modeling looking at the impact of obesity on HRQL*

InstrumentGroup & Scorep Value
NonobeseSEObeseSE
SF-36 physical
 Baseline33.400.5828.840.94Group: 0.0012

Time: 0.00001

G*T: 0.00001
 6wks28.720.7830.261.06
 1 yr40.840.6738.921.13
 2 yrs42.760.7136.521.14
ODI
 Baseline40.321.0949.291.77Group: 0.0035

Time: 0.00001

G*T: 0.0001
 6 wks47.151.2746.811.95
 1 yr26.681.2429.742.09
 2 yrs24.181.2933.192.11
SRS-22
 Baseline2.880.0422.670.069Group: 0.022

Time: 0.00001

G*T: 0.0085
 6 wks3.060.0483.070.074
 1 yr3.710.0473.570.078
 2 yrs3.760.0503.450.080

Models accounted for age, comorbidities, magnitude of surgery, and major complications including revision surgeries.

Discussion

Patient Demographic Data

Twenty-seven percent of patients included in this study were obese, with a mean age of about 60 years, which is consistent with obesity rates in the general population as defined by the Global Burden of Disease study44 and the worldwide comparative analyses of long-term trends of BMI.20 Obese patients reported higher rates of comorbidities (CCI), consistent with a report from Ezzati et al. and the WHO.16,73

In 2005, obesity overtook smoking as the most common preventable cause of illness in the US.42 Notably, these 2 problems are inversely related, with several studies associating obesity with smoking cessation,19,28,31 and weight gain being one of the main concerns for individuals who are considering smoking cessation.71 In the present study, obese patients also reported a lower incidence of smoking, which is consistent with previous reports. In the present study, obese patients were more likely to require a decompression, which is consistent with previous studies that suggested obesity is a risk factor for spinal stenosis.21,34,67

Methodology of Complications Acquisition

The complications rate in spinal surgery literature varies widely. Many factors may contribute to these variations, such as the characteristics of the studied cohort, the type of surgery performed, and the length of the follow-up. Nasser et al.,43 in a systematic review of the spinal surgery literature, reported that the rate of complications for thoracolumbar surgeries ranged from < 1% to 70%. Notably, retrospective studies have a tendency to underestimate the incidence of complications.7,43

In the present study, all sites prospectively collected complications based on a standardized data-collection form (Table 1). This methodology helped to facilitate higher accuracy and better estimation of the complications. Comparison with published works that have similar methodology, patient population, and follow-up shows that the overall, major, and minor complication rates in the present study are consistent.10,11,22,60,66,68

Obesity Versus Complications, Perioperative Metrics, and Clinical Outcomes

This study identified obesity as an independent risk factor for increased postoperative complications, even after adjusting for confounders such as comorbidities and magnitude of surgery. This is consistent with the results of other works, including a recent meta-analysis of spine surgery patients by Jiang et al.12,32,47 Their study demonstrated that obesity is an independent risk factor for surgical-site infections. These findings are consistent with the literature. 1,8,15,35,40,49,51,59 In a recent study specific to ASD, Pull ter Gunne and Cohen48 identified risk factors for wound infections in the ASD population and found obesity to be associated with both deep and superficial wound infections. Our results are consistent with these findings and contribute to the small body of evidence on this subject. In a publication looking at lumbar fusion surgery, Mehta et al.41 found that the thickness of subcutaneous fat and the skin-to-lamina distance are risk factors for surgical-site infections. This is probably due to the fact that thicker subcutaneous fat may require further retraction, leading to increased dead space postoperatively, which in turn increases the risk of infection. Further studies should specifically address the relationship between thickness of subcutaneous fat and surgical-site infection in the context of long fusions for ASD.

In the current study, obesity was not associated with radiographic or implant-related complications. This finding is consistent with recent work by Fu et al.24 Weight itself, rather than BMI, showed a trend toward increased implant-related complications. This suggests that there may be an absolute weight threshold that puts more stress on the implants, leading to higher risk of implant failure due to stress fatigue. For example, a short patient classified as obese based on BMI may not meet this weight threshold. Conversely, a very tall patient may not be classified as obese based on BMI but may still have a weight high enough to put significant stress on the implants, leading to increased risk of implant-related complications.

With regard to perioperative metrics, our data suggest that obesity is not an independent factor for increased OR time, EBL, or LOS. These findings are contrary to the results of studies based on the degenerative spine population.6,33,40,58,70,77 Our findings may be explained by the fact that ASD surgery is generally of a greater magnitude than surgery for degenerative spinal conditions, often requiring longer fusion levels and osteotomies. For example, adult deformity procedures typically involve relatively longer and more varied OR times and LOS, which may make detection of the potential impact of obesity on these parameters more difficult and perhaps relatively less significant. However, it is possible that our study may have been underpowered to detect a small difference in these metrics. Further studies with a larger surgical ASD patient population are required to confirm these findings.

In the present study, obese patients had significantly worse HRQL scores prior to the surgical treatment. This finding is consistent with previous reports suggesting that obesity can contribute to back pain, sciatica, disc-height reduction and degeneration, and eventually worse quality of life and disability.14,29,30,36–38,52,54,55,69,74 This added baseline compromise did not preclude obese patients from benefiting from surgery. After adjusting for confounders, including the incidence of major complications, our results show that obese patients do improve after ASD surgery, although not to the same extent as nonobese patients. This was true for all 3 patient-reported outcomes that were assessed (SF-36 physical, ODI, and SRS scores). Previous studies for spinal conditions other than adult deformity have also identified lower rates of improvement in HRQL scores for obese patients.11,18,34,76 However, a recent study by Rihn et al.50 that assessed a subgroup analysis of the Spine Patient Outcomes Research Trial (SPORT) showed that, in the context of spinal stenosis and degenerative spondylolisthesis, obese patients experience postoperative improvements similar to those of nonobese patients, whereas they do significantly worse with nonoperative treatment, resulting in a larger treatment effect of surgery in obese patients. Our study did not examine how obese patients benefit from nonoperative treatment, and further studies should look at this question in the ASD population.

Obesity as a Risk Factor for Reoperation

After adjusting for age, smoking status, comorbidities, previous spine surgery, and magnitude of surgery, obesity was not a significant risk factor for reoperation in the current study of ASD patients. This is contrary to the literature in the elective lumbar surgery population,25,32 but can be explained by the reality that ASD has an overall high reoperation rate (20.3% in our series). Furthermore, ASD revisions are often due to implant failure, pseudarthrosis, or proximal junctional kyphosis,46 complications that may be heightened by the biomechanical impact of excess weight.

Limitations of the Study

This study has several limitations. Due to its observational nature, the obese and nonobese groups were different in regard to baseline patient characteristics and magnitude of surgery. Although we accounted for these variables through multivariate analysis, it is possible that there are some unmeasured sources of bias that we were unable to adjust for. Moreover, due to the relatively small sample size, it is possible that our study was underpowered to detect smaller differences in some of our outcome measures, such as EBL and OR time. Additionally, it would have been interesting to examine if the super-obese patients (obesity Class III) are at even greater risk of postoperative complications. However, we were not able to do any subgroup analysis due to our sample size. Finally, although it would be interesting to follow these patients for a longer period of time to determine the long-term impact of obesity after ASD surgery, our follow-up period was limited to 2 years.

Conclusions

This study found that obese patients are a higher-risk group than the general ASD population and quantifies that risk. Despite increased complications, obese patients do benefit from ASD surgery. However, their improvement in HRQL measures appears to be less than that of nonobese patients. These findings may prove useful as part of the preoperative discussion with obese patients with ASD who are considering surgical intervention.

Author Contributions

Conception and design: Lafage, Soroceanu, Burton, Smith, Hostin, Shaffrey, Boachie-Adjei, Mundis, Ames, Errico, Bess, Gupta, Hart, Schwab. Acquisition of data: Lafage, Diebo, Smith, Hostin, Shaffrey, Boachie-Adjei, Mundis, Ames, Errico, Bess, Gupta, Hart, Schwab. Analysis and interpretation of data: Lafage, Soroceanu, Burton, Smith, Hostin, Shaffrey, Boachie-Adjei, Mundis, Ames, Errico, Bess, Gupta, Hart, Schwab. Drafting the article: Lafage, Soroceanu, Burton, Diebo. Critically revising the article: Lafage, Smith, Hostin, Shaffrey, Boachie-Adjei, Mundis, Ames, Errico, Bess, Gupta, Hart, Schwab. Statistical analysis: Lafage, Soroceanu, Burton. Administrative/technical/material support: Lafage, Soroceanu, Burton, Diebo. Study supervision: Lafage, Soroceanu, Burton, Smith, Hostin, Shaffrey, Boachie-Adjei, Mundis, Ames, Errico, Bess, Gupta, Hart, Schwab.

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    Cho SKBridwell KHLenke LGYi JSPahys JMZebala LP: Major complications in revision adult deformity surgery: risk factors and clinical outcomes with 2- to 7-year follow-up. Spine (Phila Pa 1976) 37:4895002012

  • 13

    DeWald CJStanley T: Instrumentation-related complications of multilevel fusions for adult spinal deformity patients over age 65: surgical considerations and treatment options in patients with poor bone quality. Spine (Phila Pa 1976) 31:19 SupplS144S1512006

  • 14

    Deyo RABass JE: Lifestyle and low-back pain The influence of smoking and obesity. Spine (Phila Pa 1976) 14:5015061989

  • 15

    Djurasovic MBratcher KRGlassman SDDimar JRCarreon LY: The effect of obesity on clinical outcomes after lumbar fusion. Spine (Phila Pa 1976) 33:178917922008

  • 16

    Ezzati MLopez ADRodgers AVander Hoorn SMurray CJL: Selected major risk factors and global and regional burden of disease. Lancet 360:134713602002

  • 17

    Fairbank JCPynsent PB: The Oswestry Disability Index. Spine (Phila Pa 1976) 25:29402952discussion 2952 2000

  • 18

    Fanuele JCAbdu WAHanscom BWeinstein JN: Association between obesity and functional status in patients with spine disease. Spine (Phila Pa 1976) 27:3063122002

  • 19

    Ferguson SAl-Rehany LTang CGougeon LWarwick KMadill J: Self-reported causes of weight gain: among prebariatric surgery patients. Can J Diet Pract Res 74:1891922013

  • 20

    Finucane MMStevens GACowan MJDanaei GLin JKPaciorek CJ: National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants. Lancet 377:5575672011

  • 21

    Foulongne EDerrey SOuld Slimane MLevèque STobenas ACDujardin F: Lumbar spinal stenosis: which predictive factors of favorable functional results after decompressive laminectomy?. Neurochirurgie 59:23292013

  • 22

    Fritzell PHägg OWessberg PNordwall A: Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective multicenter randomized study from the Swedish lumbar spine study group. Spine (Phila Pa 1976) 27:113111412002

  • 23

    Fu KMGBess SShaffrey CISmith JSLafage VSchwab FJ: Patients with adult spinal deformity treated operatively report greater baseline pain and disability than patients treated nonoperatively; however, deformities differ between age groups. Spine (Phila Pa 1976) 39:140114072014

  • 24

    Fu LChang MSCrandall DGRevella J: Does obesity affect surgical outcomes in degenerative scoliosis?. Spine (Phila Pa 1976) 39:204920552014

  • 25

    Gaudelli CThomas K: Obesity and early reoperation rate after elective lumbar spine surgery: a population-based study. Evid Based Spine Care J 3:11162012

  • 26

    Gepstein RShabat SArinzon ZHBerner YCatz AFol-man Y: Does obesity affect the results of lumbar decompressive spinal surgery in the elderly?. Clin Orthop Relat Res 426:1381442004

  • 27

    Glassman SDHamill CLBridwell KHSchwab FJDimar JRLowe TG: The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine (Phila Pa 1976) 32:276427702007

  • 28

    Grandi SMFilion KBGervais AJoseph LO'Loughlin JParadis G: Weight change in patients attempting to quit smoking post-myocardial infarction. Am J Med 127:641649649.e12014

  • 29

    Häuser WSchmutzer GBrähler ESchiltenwolf MHilbert A: The impact of body weight and depression on low back pain in a representative population sample. Pain Med 15:131613272014

  • 30

    Heuch IHeuch IHagen KZwart JA: Body mass index as a risk factor for developing chronic low back pain: a follow-up in the Nord-Trøndelag Health Study. Spine (Phila Pa 1976) 38:1331392013

  • 31

    Issa JSSantos PCJLVieira LPAbe TOKuperszmidt CSNakasato M: Smoking cessation and weight gain in patients with cardiovascular disease or risk factor. Int J Car-diol 172:4854872014

  • 32

    Jiang JTeng YFan ZKhan SXia Y: Does obesity affect the surgical outcome and complication rates of spinal surgery? A meta-analysis. Clin Orthop Relat Res 472:9689752014

  • 33

    Kalanithi PAArrigo RBoakye M: Morbid obesity increases cost and complication rates in spinal arthrodesis. Spine (Phila Pa 1976) 37:9829882012

  • 34

    Knutsson BMichaëlsson KSandén B: Obesity is associated with inferior results after surgery for lumbar spinal stenosis: a study of 2633 patients from the Swedish spine register. Spine (Phila Pa 1976) 38:4354412013

  • 35

    Kurtz SMLau EOng KLCarreon LWatson HAlbert T: Infection risk for primary and revision instrumented lumbar spine fusion in the Medicare population. J Neurosurg Spine 17:3423472012

  • 36

    Leboeuf-Yde C: Body weight and low back pain A systematic literature review of 56 journal articles reporting on 65 epidemiologic studies. Spine (Phila Pa 1976) 25:2262372000

  • 37

    Lidar ZBehrbalk ERegev GJSalame KKeynan OSchweiger C: Intervertebral disc height changes after weight reduction in morbidly obese patients and its effect on quality of life and radicular and low back pain. Spine (Phila Pa 1976) 37:194719522012

  • 38

    Liuke MSolovieva SLamminen ALuoma KLeino-Arjas PLuukkonen R: Disc degeneration of the lumbar spine in relation to overweight. Int J Obes (Lond) 29:9039082005

  • 39

    Lonergan TPlace HTaylor P: Acute complications following adult spinal deformity surgery in patients aged 70 years and older. J Spinal Disord Tech [epub ahead of print]2012

  • 40

    Marquez-Lara ANandyala SVSankaranarayanan SNoureldin MSingh KSankaaranrayanan S: Body mass index as a predictor of complications and mortality after lumbar spine surgery. Spine (Phila Pa 1976) 39:7988042014

  • 41

    Mehta AIBabu RKarikari IOGrunch BAgarwal VJOwens TR: 2012 Young Investigator Award winner: The distribution of body mass as a significant risk factor for lumbar spinal fusion postoperative infections. Spine (Phila Pa 1976) 37:165216562012

  • 42

    Mokdad AHMarks JSStroup DFGerberding JL: Actual causes of death in the United States, 2000. JAMA 291:123812452004

  • 43

    Nasser RYadla SMaltenfort MGHarrop JSAnderson DGVaccaro AR: Complications in spine surgery. J Neurosurg Spine 13:1441572010

  • 44

    Ng MFleming TRobinson MThomson BGraetz NMar-gono C: Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 384:7667812014

  • 45

    Park PUpadhyaya CGarton HJFoley KT: The impact of minimally invasive spine surgery on perioperative complications in overweight or obese patients. Neurosurgery 62:6936992008

  • 46

    Passias PGYang SSoroceanu ASmith SJShaffrey CBoachie-Adjei O: Predictors of revision surgery in adult spinal deformity and impact on patient-reported outcomes and satisfaction: two-year follow up. 21st International Meeting on Advanced Spine Techniques Final Program MilwaukeeScoliosis Research Society2014. Abstract #36

  • 47

    Patel NBagan BVadera SMaltenfort MGDeutsch HVaccaro AR: Obesity and spine surgery: relation to perioperative complications. J Neurosurg Spine 6:2912972007

  • 48

    Pull ter Gunne AFCohen DB: Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery. Spine (Phila Pa 1976) 34:142214282009

  • 49

    Pull ter Gunne AFvan Laarhoven CJHMCohen DB: Incidence of surgical site infection following adult spinal deformity surgery: an analysis of patient risk. Eur Spine J 19:9829882010

  • 50

    Rihn JAKurd MHilibrand ASLurie JZhao WAlbert T: The influence of obesity on the outcome of treatment of lumbar disc herniation: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am 95:182013

  • 51

    Rihn JARadcliff KHilibrand ASAnderson DTZhao WLurie J: Does obesity affect outcomes of treatment for lumbar stenosis and degenerative spondylolisthesis? Analysis of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 37:193319462012

  • 52

    Rissanen AHeliövaara MKnekt PReunanen AAromaa AMaatela J: Risk of disability and mortality due to overweight in a Finnish population. BMJ 301:8358371990

  • 53

    Rosen DSFerguson SDOgden ATHuo DFessler RG: Obesity and self-reported outcome after minimally invasive lumbar spinal fusion surgery. Neurosurgery 63:9569602008

  • 54

    Samartzis DKarppinen JChan DLuk KDKCheung KMC: The association of lumbar intervertebral disc degeneration on magnetic resonance imaging with body mass index in overweight and obese adults: a population-based study. Arthritis Rheum 64:148814962012

  • 55

    Samartzis DKarppinen JCheung JPYLotz J: Disk degeneration and low back pain: are they fat-related conditions?. Global Spine J 3:1331442013

  • 56

    Schwab FDubey AGamez LEl Fegoun ABHwang KPagala MFarcy JP: Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976) 30:108210852005

  • 57

    Schwab FJHawkinson NLafage VSmith JSHart RMundis G: Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J 21:260326102012

  • 58

    Seicean AAlan NSeicean SWorwag MNeuhauser DBenzel EC: Impact of increased body mass index on outcomes of elective spinal surgery. Spine (Phila Pa 1976) 39:152015302014

  • 59

    Shamji MFParker SCook CPietrobon RBrown CIsaacs RE: Impact of body habitus on perioperative morbidity associated with fusion of the thoracolumbar and lumbar spine. Neurosurgery 65:4904982009

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    Simmons ED JrKowalski JMSimmons EH: The results of surgical treatment for adult scoliosis. Spine (Phila Pa 1976) 18:7187241993

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    Smith JSKasliwal MKCrawford AHShaffrey CI: Outcomes, expectations, and complications overview for the surgical treatment of adult and pediatric spinal deformity. Spine Deform [epub ahead of print]2012

  • 62

    Smith JSShaffrey CIBerven SGlassman SHamill CHorton W: Improvement of back pain with operative and nonoperative treatment in adults with scoliosis. Neurosurgery 65:86942009

  • 63

    Smith JSShaffrey CIBerven SGlassman SHamill CHorton W: Operative versus nonoperative treatment of leg pain in adults with scoliosis: a retrospective review of a prospective multicenter database with two-year follow-up. Spine (Phila Pa 1976) 34:169316982009

  • 64

    Smith JSShaffrey CIGlassman SDCarreon LYSchwab FJLafage V: Clinical and radiographic parameters that distinguish between the best and worst outcomes of scoliosis surgery for adults. Eur Spine J 22:4024102013

  • 65

    Srinivasan DLa Marca FThan KDPatel RDPark P: Peri-operative characteristics and complications in obese patients undergoing anterior cervical fusion surgery. J Clin Neurosci 21:115911622014

  • 66

    Swank SLonstein JEMoe JHWinter RBBradford DS: Surgical treatment of adult scoliosis A review of two hundred and twenty-two cases. J Bone Joint Surg Am 63:2682871981

  • 67

    Tomkins-Lane CCLafave LMZParnell JAKrishnamurthy ARempel JMacedo LG: The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI) randomized controlled trial protocol. BMC Musculoskelet Disord 14:3222013

  • 68

    Uribe JSDeukmedjian ARMummaneni PVFu KMGMundis GM JrOkonkwo DO: Complications in adult spinal deformity surgery: an analysis of minimally invasive, hybrid, and open surgical techniques. Neurosurg Focus 36:5E152014

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    Urquhart DMKurniadi ITriangto KWang YWluka AEO’sullivan R: Obesity is associated with reduced disc height in the lumbar spine but not at the lumbosacral junction. Spine (Phila Pa 1976) 39:E962E9662014

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    Vaidya RCarp JBartol SOuellette NLee SSethi A: Lumbar spine fusion in obese and morbidly obese patients. Spine (Phila Pa 1976) 34:4955002009

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    Yadla SMalone JCampbell PGMaltenfort MGHarrop JSSharan AD: Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures. Spine J 10:5815872010

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    Yagi MPatel RBoachie-Adjei O: Complications and unfavorable clinical outcomes in obese and overweight patients treated for adult lumbar or thoracolumbar scoliosis with combined anterior/posterior surgery. J Spinal Disord Tech [epub ahead of print]2013

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    Zheng FCammisa FP JrSandhu HSGirardi FPKhan SN: Factors predicting hospital stay, operative time, blood loss, and transfusion in patients undergoing revision posterior lumbar spine decompression, fusion, and segmental instrumentation. Spine (Phila Pa 1976) 27:8188242002

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Article Information

Correspondence Virginie Lafage, Orthopaedic Surgery, NYU Hospital for Joint Diseases, 306 East 15th St., New York, NY 10003. E-mail: virginie.lafage@gmail.com.

INCLUDE WHEN CITING Published online July 31, 2015; DOI: 10.3171/2015.3.SPINE14743.

DISCLOSURE A DePuy Spine grant was received by the International Spine Study Group Foundation (ISSGF).

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Results of multivariate repeated-measures mixed models show the difference between SF-36 physical scores in obese versus nonobese groups at baseline and at 6-week, 1-year, and 2-year follow-up. Figure is available in color online only.

  • View in gallery

    Results of multivariate repeated-measures mixed models show the difference between ODI scores in obese versus nonobese groups at baseline and at 6-week, 1-year, and 2-year follow-up. Figure is available in color online only.

  • View in gallery

    Results of multivariate repeated-measures mixed models show the difference between SRS scores in obese versus nonobese groups at baseline and at 6-week, 1-year, and 2-year follow-up. Figure is available in color online only.

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Bridwell KHGlassman SHorton WShaffrey CSchwab FZebala LP: Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis: a prospective multicenter evidence-based medicine study. Spine (Phila Pa 1976) 34:217121782009

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Charosky SGuigui PBlamoutier ARoussouly PChopin D: Complications and risk factors of primary adult scoliosis surgery: a multicenter study of 306 patients. Spine (Phila Pa 1976) 37:6937002012

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Cho SKBridwell KHLenke LGCho WZebala LPPahys JM: Comparative analysis of clinical outcome and complications in primary versus revision adult scoliosis surgery. Spine (Phila Pa 1976) 37:3934012012

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Cho SKBridwell KHLenke LGYi JSPahys JMZebala LP: Major complications in revision adult deformity surgery: risk factors and clinical outcomes with 2- to 7-year follow-up. Spine (Phila Pa 1976) 37:4895002012

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DeWald CJStanley T: Instrumentation-related complications of multilevel fusions for adult spinal deformity patients over age 65: surgical considerations and treatment options in patients with poor bone quality. Spine (Phila Pa 1976) 31:19 SupplS144S1512006

14

Deyo RABass JE: Lifestyle and low-back pain The influence of smoking and obesity. Spine (Phila Pa 1976) 14:5015061989

15

Djurasovic MBratcher KRGlassman SDDimar JRCarreon LY: The effect of obesity on clinical outcomes after lumbar fusion. Spine (Phila Pa 1976) 33:178917922008

16

Ezzati MLopez ADRodgers AVander Hoorn SMurray CJL: Selected major risk factors and global and regional burden of disease. Lancet 360:134713602002

17

Fairbank JCPynsent PB: The Oswestry Disability Index. Spine (Phila Pa 1976) 25:29402952discussion 2952 2000

18

Fanuele JCAbdu WAHanscom BWeinstein JN: Association between obesity and functional status in patients with spine disease. Spine (Phila Pa 1976) 27:3063122002

19

Ferguson SAl-Rehany LTang CGougeon LWarwick KMadill J: Self-reported causes of weight gain: among prebariatric surgery patients. Can J Diet Pract Res 74:1891922013

20

Finucane MMStevens GACowan MJDanaei GLin JKPaciorek CJ: National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants. Lancet 377:5575672011

21

Foulongne EDerrey SOuld Slimane MLevèque STobenas ACDujardin F: Lumbar spinal stenosis: which predictive factors of favorable functional results after decompressive laminectomy?. Neurochirurgie 59:23292013

22

Fritzell PHägg OWessberg PNordwall A: Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective multicenter randomized study from the Swedish lumbar spine study group. Spine (Phila Pa 1976) 27:113111412002

23

Fu KMGBess SShaffrey CISmith JSLafage VSchwab FJ: Patients with adult spinal deformity treated operatively report greater baseline pain and disability than patients treated nonoperatively; however, deformities differ between age groups. Spine (Phila Pa 1976) 39:140114072014

24

Fu LChang MSCrandall DGRevella J: Does obesity affect surgical outcomes in degenerative scoliosis?. Spine (Phila Pa 1976) 39:204920552014

25

Gaudelli CThomas K: Obesity and early reoperation rate after elective lumbar spine surgery: a population-based study. Evid Based Spine Care J 3:11162012

26

Gepstein RShabat SArinzon ZHBerner YCatz AFol-man Y: Does obesity affect the results of lumbar decompressive spinal surgery in the elderly?. Clin Orthop Relat Res 426:1381442004

27

Glassman SDHamill CLBridwell KHSchwab FJDimar JRLowe TG: The impact of perioperative complications on clinical outcome in adult deformity surgery. Spine (Phila Pa 1976) 32:276427702007

28

Grandi SMFilion KBGervais AJoseph LO'Loughlin JParadis G: Weight change in patients attempting to quit smoking post-myocardial infarction. Am J Med 127:641649649.e12014

29

Häuser WSchmutzer GBrähler ESchiltenwolf MHilbert A: The impact of body weight and depression on low back pain in a representative population sample. Pain Med 15:131613272014

30

Heuch IHeuch IHagen KZwart JA: Body mass index as a risk factor for developing chronic low back pain: a follow-up in the Nord-Trøndelag Health Study. Spine (Phila Pa 1976) 38:1331392013

31

Issa JSSantos PCJLVieira LPAbe TOKuperszmidt CSNakasato M: Smoking cessation and weight gain in patients with cardiovascular disease or risk factor. Int J Car-diol 172:4854872014

32

Jiang JTeng YFan ZKhan SXia Y: Does obesity affect the surgical outcome and complication rates of spinal surgery? A meta-analysis. Clin Orthop Relat Res 472:9689752014

33

Kalanithi PAArrigo RBoakye M: Morbid obesity increases cost and complication rates in spinal arthrodesis. Spine (Phila Pa 1976) 37:9829882012

34

Knutsson BMichaëlsson KSandén B: Obesity is associated with inferior results after surgery for lumbar spinal stenosis: a study of 2633 patients from the Swedish spine register. Spine (Phila Pa 1976) 38:4354412013

35

Kurtz SMLau EOng KLCarreon LWatson HAlbert T: Infection risk for primary and revision instrumented lumbar spine fusion in the Medicare population. J Neurosurg Spine 17:3423472012

36

Leboeuf-Yde C: Body weight and low back pain A systematic literature review of 56 journal articles reporting on 65 epidemiologic studies. Spine (Phila Pa 1976) 25:2262372000

37

Lidar ZBehrbalk ERegev GJSalame KKeynan OSchweiger C: Intervertebral disc height changes after weight reduction in morbidly obese patients and its effect on quality of life and radicular and low back pain. Spine (Phila Pa 1976) 37:194719522012

38

Liuke MSolovieva SLamminen ALuoma KLeino-Arjas PLuukkonen R: Disc degeneration of the lumbar spine in relation to overweight. Int J Obes (Lond) 29:9039082005

39

Lonergan TPlace HTaylor P: Acute complications following adult spinal deformity surgery in patients aged 70 years and older. J Spinal Disord Tech [epub ahead of print]2012

40

Marquez-Lara ANandyala SVSankaranarayanan SNoureldin MSingh KSankaaranrayanan S: Body mass index as a predictor of complications and mortality after lumbar spine surgery. Spine (Phila Pa 1976) 39:7988042014

41

Mehta AIBabu RKarikari IOGrunch BAgarwal VJOwens TR: 2012 Young Investigator Award winner: The distribution of body mass as a significant risk factor for lumbar spinal fusion postoperative infections. Spine (Phila Pa 1976) 37:165216562012

42

Mokdad AHMarks JSStroup DFGerberding JL: Actual causes of death in the United States, 2000. JAMA 291:123812452004

43

Nasser RYadla SMaltenfort MGHarrop JSAnderson DGVaccaro AR: Complications in spine surgery. J Neurosurg Spine 13:1441572010

44

Ng MFleming TRobinson MThomson BGraetz NMar-gono C: Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 384:7667812014

45

Park PUpadhyaya CGarton HJFoley KT: The impact of minimally invasive spine surgery on perioperative complications in overweight or obese patients. Neurosurgery 62:6936992008

46

Passias PGYang SSoroceanu ASmith SJShaffrey CBoachie-Adjei O: Predictors of revision surgery in adult spinal deformity and impact on patient-reported outcomes and satisfaction: two-year follow up. 21st International Meeting on Advanced Spine Techniques Final Program MilwaukeeScoliosis Research Society2014. Abstract #36

47

Patel NBagan BVadera SMaltenfort MGDeutsch HVaccaro AR: Obesity and spine surgery: relation to perioperative complications. J Neurosurg Spine 6:2912972007

48

Pull ter Gunne AFCohen DB: Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery. Spine (Phila Pa 1976) 34:142214282009

49

Pull ter Gunne AFvan Laarhoven CJHMCohen DB: Incidence of surgical site infection following adult spinal deformity surgery: an analysis of patient risk. Eur Spine J 19:9829882010

50

Rihn JAKurd MHilibrand ASLurie JZhao WAlbert T: The influence of obesity on the outcome of treatment of lumbar disc herniation: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am 95:182013

51

Rihn JARadcliff KHilibrand ASAnderson DTZhao WLurie J: Does obesity affect outcomes of treatment for lumbar stenosis and degenerative spondylolisthesis? Analysis of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 37:193319462012

52

Rissanen AHeliövaara MKnekt PReunanen AAromaa AMaatela J: Risk of disability and mortality due to overweight in a Finnish population. BMJ 301:8358371990

53

Rosen DSFerguson SDOgden ATHuo DFessler RG: Obesity and self-reported outcome after minimally invasive lumbar spinal fusion surgery. Neurosurgery 63:9569602008

54

Samartzis DKarppinen JChan DLuk KDKCheung KMC: The association of lumbar intervertebral disc degeneration on magnetic resonance imaging with body mass index in overweight and obese adults: a population-based study. Arthritis Rheum 64:148814962012

55

Samartzis DKarppinen JCheung JPYLotz J: Disk degeneration and low back pain: are they fat-related conditions?. Global Spine J 3:1331442013

56

Schwab FDubey AGamez LEl Fegoun ABHwang KPagala MFarcy JP: Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976) 30:108210852005

57

Schwab FJHawkinson NLafage VSmith JSHart RMundis G: Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J 21:260326102012

58

Seicean AAlan NSeicean SWorwag MNeuhauser DBenzel EC: Impact of increased body mass index on outcomes of elective spinal surgery. Spine (Phila Pa 1976) 39:152015302014

59

Shamji MFParker SCook CPietrobon RBrown CIsaacs RE: Impact of body habitus on perioperative morbidity associated with fusion of the thoracolumbar and lumbar spine. Neurosurgery 65:4904982009

60

Simmons ED JrKowalski JMSimmons EH: The results of surgical treatment for adult scoliosis. Spine (Phila Pa 1976) 18:7187241993

61

Smith JSKasliwal MKCrawford AHShaffrey CI: Outcomes, expectations, and complications overview for the surgical treatment of adult and pediatric spinal deformity. Spine Deform [epub ahead of print]2012

62

Smith JSShaffrey CIBerven SGlassman SHamill CHorton W: Improvement of back pain with operative and nonoperative treatment in adults with scoliosis. Neurosurgery 65:86942009

63

Smith JSShaffrey CIBerven SGlassman SHamill CHorton W: Operative versus nonoperative treatment of leg pain in adults with scoliosis: a retrospective review of a prospective multicenter database with two-year follow-up. Spine (Phila Pa 1976) 34:169316982009

64

Smith JSShaffrey CIGlassman SDCarreon LYSchwab FJLafage V: Clinical and radiographic parameters that distinguish between the best and worst outcomes of scoliosis surgery for adults. Eur Spine J 22:4024102013

65

Srinivasan DLa Marca FThan KDPatel RDPark P: Peri-operative characteristics and complications in obese patients undergoing anterior cervical fusion surgery. J Clin Neurosci 21:115911622014

66

Swank SLonstein JEMoe JHWinter RBBradford DS: Surgical treatment of adult scoliosis A review of two hundred and twenty-two cases. J Bone Joint Surg Am 63:2682871981

67

Tomkins-Lane CCLafave LMZParnell JAKrishnamurthy ARempel JMacedo LG: The spinal stenosis pedometer and nutrition lifestyle intervention (SSPANLI) randomized controlled trial protocol. BMC Musculoskelet Disord 14:3222013

68

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