Identifying Risk Factors for Complications During Exposure for Anterior Lumbar Interbody Fusion

Abstract

Introduction An anterior approach to lumbar interbody fusion is a widely utilized method of access to the lumbar spine. Due to the potential for vascular complications with spine exposure, vascular surgeons are frequently included in the care of these patients as part of a team-based approach. Identifying risk factors for such complications is difficult and not well-defined in the literature. In this investigation, we evaluate the potential risk factors for complications during anterior lumbar inter-body fusion (ALIF). Methods This is a retrospective review of 106 patients who underwent ALIF at a single institution between May 1, 2007, and April 30, 2017. Patients were identified through operating room case logs and Current Procedural Terminology (CPT) codes correlating with ALIF. Vascular surgeons performed all anterior exposures. Patient demographics and data regarding their surgical care and postoperative course were obtained from a review of operative and progress notes in the electronic medical record. Statistical methods employed included a t-test for normally distributed data and the Wilcoxon rank-sum test for non-normally distributed data. Categorical variables were compared using Fisher’s exact and chi-square tests. A logistic regression model was applied to predict complications by controlling other significant covariates. Results Of the 106 patients included in this analysis, 16 patients experienced a defined complication, giving an overall complication rate of 15%. Patients with complications were more likely to be of male gender (n=11, P=0.016), with older average age (54.6, P=0.017), with higher estimated blood loss, with higher use of blood products, and with higher use of cell-saver. A venous injury was the most common complication (n=11, 10.4%); ileus and nerve injury were the next most common (n=3, 2.8%). The 30-day mortality was 0%. Male gender demonstrated an odds ratio of 3.78 (P=0 .034) in a logistic regression model after adjusting for age and blood products. Conclusions Overall complication rates were comparable to those in the published literature and male gender was identified as a predictor for risk of complications in those undergoing ALIF. This is the first study to identify male sex as a risk factor for complications following ALIF. The results of this study will hopefully guide future studies in gaining more insight into the predictors of complications in larger series.

Reduction of spondylolisthesis and restoration of lumbar lordosis after anterior lumbar interbody fusion (ALIF)

“…Rates of vascular injury vary between different studies. A recent review found a venous injury rate of 10.4%, similar to the rate we found in our study [ 20 ]. Another review reports a wide range of vascular injury rates, from 0% up to 18.1%, with arterial injuries being less frequent than venous lacerations [ 21 ].…”

Who bleeds during elective anterior lumbar surgery?

“…Age showed a strong positive correlation with elevated BL. Other studies have supported this [ 6 , 15 ]. We postulate this is due to diminution of the supportive perivascular connective tissues which renders the small vessels more prone to disruption.…”

Endovascular Repair of Iatrogenic Inferior Vena Cava and Iliac Vein Injury: A Case Series and Review of the Literature

“…[22][23][24][25][26] Male sex, older age, history of previous abdominal surgery and prior spinal instrumentation are associated with additional risk. 27,28 Our review findings were in keeping with these data, as 81.8% of the subset of patients with venous injury during anterior spinal exposures had undergone prior lumbar surgery. Given this well described risk, obtaining routine pre-operative evaluation of vessel anatomy with imaging as well as utilization of a vascular surgeon to assist with exposure may be beneficial.…”