The impact of obesity on perioperative complications in patients undergoing anterior lumbar interbody fusion

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  • 1 Department of Neurological Surgery, University of California, San Francisco;
  • 2 Department of Orthopedic Surgery, Stanford University, Palo Alto; and
  • 3 Departments of Orthopedic Surgery and
  • 4 Vascular Surgery, University of California, San Francisco, California
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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.

ABBREVIATIONS ALIF = anterior lumbar interbody fusion; BMI = body mass index; BMP = bone morphogenetic protein; CCI = Charlson Comorbidity Index; DVT = deep venous thrombosis; EBL = estimated blood loss; LOS = length of stay; PE = pulmonary embolism; UTI = urinary tract infection.

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Contributor Notes

Correspondence Aaron J. Clark: University of California, San Francisco, CA. aaron.clark@ucsf.edu.

INCLUDE WHEN CITING Published online April 24, 2020; DOI: 10.3171/2020.2.SPINE191418.

M.M.S. and A.T. contributed equally to this work.

Disclosures Dr. Tay reports being a consultant for Biomet, Stryker, DePuy Synthes, and Lumetra, and receiving institutional fellowship support from NuVasive and Omega. Dr. Burch reports being a consultant for Medtronic and an ownership stake in Zimmer Biomet. Dr. Berven reports an ownership stake in Green Sun Medical, receiving royalties from Stryker Spine, and being a consultant for Medtronic, Medicrea, and Integrity Spine. Dr. Deviren reports being a consultant for NuVasive, Biomet, Medicrea, Alphatec, and Seaspine; receiving royalties from NuVasive; and receiving institutional fellowship support from Omega and NuVasive. Dr. Dhall reports receiving honoraria from DePuy and Globus. Dr. Chou reports being a consultant for Globus and Medtronic and receiving royalties from Globus. Dr. Mummaneni reports being a consultant for DePuy Synthes, Stryker, and Globus; direct stock ownership in Spinicity/ISD; receiving royalties from DePuy Synthes, Thieme, and Springer; and support from NREF and AOSpine for clinical or research efforts not related to this work. Dr. Ames reports receiving royalties from Stryker, Biomet Zimmer Spine, DePuy Synthes, NuVasive, Next Orthosurgical, K2M, and Medicrea; being a consultant for DePuy Synthes, Medtronic, Stryker, Medicrea, K2M, and Biomet Zimmer; research support from Titan Spine, DePuy Synthes, and ISSG; receiving grant funding from SRS; and serving on the editorial board of Operative Neurosurgery, on the executive committee of ISSG, and as a director for Global Spinal Analytics. Dr. Clark reports being a consultant for NuVasive.

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