Risk factors for wound-related reoperations in patients with metastatic spine tumor

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OBJECTIVE

Resection of metastatic spine tumors can improve patients’ quality of life by addressing pain or neurological compromise. However, resections are often complicated by wound dehiscence, infection, instrumentation failures, and the need for reoperation. Moreover, when reoperations are needed, the most common indication is surgical site infection and wound breakdown. In turn, wound reoperations increase morbidity as well as the length and cost of hospitalization. The aim of this study was to examine perioperative risk factors associated with increased rate of wound reoperations after metastatic spine tumor resection.

METHODS

A retrospective study of patients at a single institution who underwent metastatic spine tumor resection between 2003 and 2013 was conducted. Factors with a p value < 0.200 in a univariate analysis were included in the multivariate model.

RESULTS

A total of 159 patients were included in this study. Karnofsky Performance Scale score > 70, smoking status, hypertension, thromboembolic events, hyperlipidemia, increasing number of vertebral levels, and posterior approach were included in the multivariate analysis. Thromboembolic events (95% CI 1.19–48.5, p = 0.032) and number of levels involved were independently associated with increased wound reoperation rates in the multivariate model. For each additional spinal level involved, the risk for wound reoperations increased by 21% (95% CI 1.03–1.43, p = 0.018).

CONCLUSIONS

Although wound complications and subsequent reoperations are potential risks for all patients with metastatic spine tumor, due to adjuvant radiotherapy and other medical comorbidities, this study identified patients with thromboembolic events or those requiring a larger incision as being at the highest risk. Measures intended to decrease the occurrence of perioperative venous thromboembolism and to improve wound care, especially for long incisions, may decrease wound-related revision surgeries in this vulnerable group of patients.

ABBREVIATIONS BMI = body mass index; CAD = coronary artery disease; COPD = chronic obstructive pulmonary disease; DM = diabetes mellitus; EBL = estimated blood loss; KPS = Karnofsky Performance Scale; RT = radiation therapy; VEGF = vascular endothelial growth factor; VTE = venous thromboembolism.

Article Information

Correspondence C. Rory Goodwin: Duke University Medical Center, Durham, NC. rory.goodwin@duke.edu.

INCLUDE WHEN CITING Published online March 16, 2018; DOI: 10.3171/2017.10.SPINE1765.

H.M.C., A.K.A., and N.A.B. contributed equally to this work.

Disclosures Mr. Ahmed had a Neurosurgery Research and Education Foundation (NREF) Medical Student Summer Research Fellowship. Dr. Goodwin is a United Negro College Fund (UNCF) Merck Postdoctoral Fellow and has received an award from the Burroughs Wellcome Fund, the NIH/NINDS Neurosurgeon Research Career Development Program (NRCDP) K12 Physician Scientist Award, and the North Carolina Spine Society. Dr. Bydon has a research grant from DePuy Spine and serves on the clinical advisory board of MedImmune, LLC. Dr. Witham receives support of a non–study-related clinical or research effort that he oversees in a grant from Eli Lilly and Co., and from the Gordon and Marilyn Macklin Foundation. Dr. Gokaslan has stock ownership in US Spine and Spinal Kinetics; receives consulting, speaking, and teaching fees from the AO Foundation; and receives research support from DePuy, NREF, AOSpine, and AO North America. Dr. Sacks has a consulting relationship with LifeCell, Inc. Dr. Sciubba has consulting relationships with Medtronic, Globus, DePuy-Synthes, Stryker, K2M, and NuVasive.

© AANS, except where prohibited by US copyright law.

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References

  • 1

    Boriani SBandiera SDonthineni RAmendola LCappuccio MDe Iure F: Morbidity of en bloc resections in the spine. Eur Spine J 19:2312412010

  • 2

    Buerba RAFu MCGruskay JALong WD IIIGrauer JN: Obese Class III patients at significantly greater risk of multiple complications after lumbar surgery: an analysis of 10,387 patients in the ACS NSQIP database. Spine J 14:200820182014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Capen DACalderone RRGreen A: Perioperative risk factors for wound infections after lower back fusions. Orthop Clin North Am 27:83861996

  • 4

    Chieng LOHubbard ZSalgado CJLevi ADChim H: Reconstruction of open wounds as a complication of spinal surgery with flaps: a systematic review. Neurosurg Focus 39(4):E172015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Cox JBWeaver KJNeal DWJacob RPHoh DJ: Decreased incidence of venous thromboembolism after spine surgery with early multimodal prophylaxis: Clinical article. J Neurosurg Spine 21:6776842014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    De la Garza Ramos RGoodwin CRJain AAbu-Bonsrah NFisher CGBettegowdaC: Development of a metastatic spinal tumor frailty index (MSTFI) using a nationwide database and its association with inpatient morbidity, mortality, and length of stay after spine surgery. World Neurosurg 95:548555555.e1–555.e42016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    De la Garza Ramos RJain ANakhla JNasser RPuvanesarajah VHassanzadeh H: Postoperative morbidity and mortality after elective anterior cervical fusion in patients with chronic and end-stage renal disease. World Neurosurg 95:4804852016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Demura SKawahara NMurakami HNambu KKato SYoshioka K: Surgical site infection in spinal metastasis: risk factors and countermeasures. Spine (Phila Pa 1976) 34:6356392009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Dipasco PJMisra SKoniaris LGMoffat FL Jr: Thrombophilic state in cancer, part I: biology, incidence, and risk factors. J Surg Oncol 104:3163222011

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Dumanian GAOndra SLLiu JSchafer MFChao JD: Muscle flap salvage of spine wounds with soft tissue defects or infection. Spine (Phila Pa 1976) 28:120312112003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Ferres MAOlivarez SATrinh VDavidson CSangi-Haghpeykar HAagaard-Tillery KM: Rate of wound complications with enoxaparin use among women at high risk for postpartum thrombosis. Obstet Gynecol 117:1191242011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Flexman AMCharest-Morin RStobart LStreet JRyerson CJ: Frailty and postoperative outcomes in patients undergoing surgery for degenerative spine disease. Spine J 16:131513232016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Garvey PBRhines LDDong WChang DW: Immediate soft-tissue reconstruction for complex defects of the spine following surgery for spinal neoplasms. Plast Reconstr Surg 125:146014662010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Gephart MGZygourakis CCArrigo RTKalanithi PSLad SPBoakye M: Venous thromboembolism after thoracic/thoracolumbar spinal fusion. World Neurosurg 78:5455522012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Gilbert RWKim JHPosner JB: Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Ann Neurol 3:40511978

  • 16

    Haubner FOhmann EPohl FStrutz JGassner HG: Wound healing after radiation therapy: review of the literature. Radiat Oncol 7:1622012

  • 17

    Levitan NDowlati ARemick SCTahsildar HISivinski LDBeyth R: Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data. Medicine (Baltimore) 78:2852911999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Luzzati ADShah SPGagliano FSPerrucchini GGFontanella WAlloisio M: Four- and five-level en bloc spondylectomy for malignant spinal tumors. Spine (Phila Pa 1976) 39:E129E1392014

    • Search Google Scholar
    • Export Citation
  • 19

    Maccauro GSpinelli MSMauro SPerisano CGraci CRosa MA: Physiopathology of spine metastasis. Int J Surg Oncol 2011:1079692011

  • 20

    McPhee IBWilliams RPSwanson CE: Factors influencing wound healing after surgery for metastatic disease of the spine. Spine (Phila Pa 1976) 23:7267331998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Mericli AFTarola NAMoore JH JrCopit SEFox JW IVTuma GA: Paraspinous muscle flap reconstruction of complex midline back wounds: risk factors and postreconstruction complications. Ann Plast Surg 65:2192242010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Mesfin ASciubba DMDea NNater ABird JEQuraishi NA: Changing the adverse event profile in metastatic spine surgery: an evidence-based approach to target wound complications and instrumentation failure. Spine (Phila Pa 1976) 41 (Suppl 20):S262S2702016

    • Search Google Scholar
    • Export Citation
  • 23

    Omeis IADhir MSciubba DMGottfried ONMcGirt MJAttenello FJ: Postoperative surgical site infections in patients undergoing spinal tumor surgery: incidence and risk factors. Spine (Phila Pa 1976) 36:141014192011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Pascal-Moussellard HBroc GPointillart VSiméon FVital JMSénégas J: Complications of vertebral metastasis surgery. Eur Spine J 7:4384441998

  • 25

    Quraishi NAEsler C: Metastatic spinal cord compression. BMJ 342:d24022011

  • 26

    Quraishi NARajabian ASpencer AArealis GMehdian HBoszczyk BM: Reoperation rates in the surgical treatment of spinal metastases. Spine J 15 (3 Suppl):S37S432015

    • Search Google Scholar
    • Export Citation
  • 27

    Rokito SESchwartz MCNeuwirth MG: Deep vein thrombosis after major reconstructive spinal surgery. Spine (Phila Pa 1976) 21:8538591996

  • 28

    Sebastian ASCurrier BLClarke MJLarson DHuddleston PM IIINassr A: Thromboembolic disease after cervical spine surgery: a review of 5,405 surgical procedures and matched cohort analysis. Global Spine J 6:4654712016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Sindali KRose BSoueid HJeer PSaran DShrivastava R: Elective hip and knee arthroplasty and the effect of rivaroxaban and enoxaparin thromboprophylaxis on wound healing. Eur J Orthop Surg Traumatol 23:4814862013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Sundaresan NRothman AManhart KKelliher K: Surgery for solitary metastases of the spine: rationale and results of treatment. Spine (Phila Pa 1976) 27:180218062002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Takahashi HYokoyama YIida YTerashima FHasegawa KSaito T: Incidence of venous thromboembolism after spine surgery. J Orthop Sci 17:1141172012

  • 32

    Tominaga HSetoguchi TTanabe FKawamura ITsuneyoshi YKawabata N: Risk factors for venous thromboembolism after spine surgery. Medicine (Baltimore) 94:e4662015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Weigel BMaghsudi MNeumann CKretschmer RMüller FJNerlich M: Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life. Spine (Phila Pa 1976) 24:224022461999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Wise JJFischgrund JSHerkowitz HNMontgomery DKurz LT: Complication, survival rates, and risk factors of surgery for metastatic disease of the spine. Spine (Phila Pa 1976) 24:194319511999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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