Complexities of spine surgery in obese patient populations: a narrative review

Abstract

The obese population is particularly challenging to the spine surgeon in all phases of care. A narrative literature review was performed to review difficulties in spine surgery on the obese patient population and techniques for mitigation. We specifically aimed to assess several topics with regard to this population: patient selection and preoperative care; intraoperative and surgical techniques; and postoperative care, outcomes, and complications. The literature review demonstrated that obese patients are at increased surgical risk with spine surgery due to a variety of factors at all stages of intervention. Preoperatively, obese patients have worse outcomes with physical therapy and present technical difficulties for injections. Transport to a hospital, imaging, resuscitation, and intubation are all challenged by increased body habitus. Intraoperatively, obese patients have increased operative times, blood loss, surgical site infections, and nerve palsies. Patient positioning and intraoperative imaging may be limited. Surgery itself may be technically challenging due to body habitus and minimally invasive techniques are becoming more prevalent in this population. Postoperatively, several studies demonstrate that obese patients have inferior outcomes compared with nonobese counterparts. Patient selection is a key for elective interventions, and appropriate infrastructure aids in the ultimate outcomes for both elective and nonelective surgical treatments. Overall, obese patients present several challenges to the spine surgeon, and certain precautions can be undertaken preoperatively, intraoperatively, and postoperatively to mitigate the associated risks to optimize outcomes.

Intraoperative neurophysiological monitoring of T9-T10 fracture in a patient with morbid obesity and ankylosing spondylitis: A case report with literature review

“…There are a limited number of reports on the use of IONM in spinal surgery for obese patients. We conducted a literature review using the following keywords in PubMed and Google Scholar: “spine surgery,” “obes*,” “morbid* obes*,” “intraoperative neurophysiological monitoring,” and “intraoperative neuromonitoring.” A total of 220 references were reviewed in this study, including the full bibliographies of four recently published systematic review articles on either spine surgery in obese patients or the use of IONM in spine surgery ( Charalampidis et al, 2020 , Daniel et al, 2018 , Goyal et al, 2019 , Katsevman et al, 2020 ). Several articles in the literature discussed the intraoperative management of anesthesia during spine surgery for obese patients, but only two studies were identified that reported on the use of IONM during spine surgery in this patient population ( Kim et al, 2007 , Rodgers et al, 2010 ).…”

“…The use of intraoperative neurophysiological monitoring (IONM) with somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (tcMEPs) is highly recommended for spinal surgery when the risk of complication is high, as may be the case for patients with morbid obesity ( Clark et al, 2013 , Stecker, 2012 ). However, there are currently few studies evaluating the unique challenges and benefits of IONM in spinal surgery for obese patients, despite ample evidence of their increased risk for spinal injury and the difficulties associated with patient positioning and intraoperative imaging ( Katsevman et al, 2020 ). This case report highlights the importance of neurophysiological monitoring and challenges that we are facing in spinal surgery for morbidly obese patients, even when a minimally invasive approach is planned.…”

Complications of Spine Surgery in “Super Obese” Patients

“…21 Consideration should be given to additional steps that may help mitigate the challenges of operating on the super obese population, such as utilizing minimally invasive techniques when feasible, intrawound antibiotics, and early postoperative mobilization. 21 Further research on these mitigation strategies in the super obese population would be worthwhile.…”

The Role of Nutrition in Degenerative Cervical Myelopathy: A Systematic Review

“…64 Conversely, the implications of increased BMI extend beyond just nutrition. An increased BMI can create challenges throughout spinal surgical care, [65][66][67] including diagnostic imaging, response to physical therapy, intubation and on-table position, surgical technique and susceptibility to peri-operative complications. Most of these challenges relate to body habitus; for example, in general positioning, or raised intrabdominal pressure increase intravenous pressure, contributing to increased operative blood loss and risk of thrombosis, however, the underlying mechanism is likely multifaceted.…”