Prevalence and Complications of Postoperative Transfusion for Cervical Fusion Procedures in Spine Surgery: An Analysis of 11,588 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

Abstract

Study DesignRetrospective cohort study.PurposeThe purpose of this study was to assess the rate of blood transfusion after cervical fusion surgery, and its effect on complication rates.Overview of LiteratureCervical spine fusions have gained interest in the literature since these procedures are now ever more frequently being performed in an outpatient setting with few complications.MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent cervical fusion from 2010 to 2013. Multivariate regression analysis was used to determine postoperative complications associated with transfusion and cervical fusion.ResultsWe identified 11,588 patients who had cervical fusion between 2010 and 2013. The rate of blood transfusion following cervical fusion found to be 1.47%. All transfused patients were found to have increased risk of venous thromboembolism (TBE) (odds ratio [OR], 3.19; 95% confidence interval [95% CI], 1.16–8.77), myocardial infarction (MI) (OR, 9.12; 95% CI, 2.53–32.8), increased length of stay (LOS) (OR, 28.03; 95% CI, 14.28–55.01) and mortality (OR, 4.14; 95% CI, 1.44–11.93). Single level fusion had increased risk of TBE (OR, 3.37; 95% CI, 1.01–11.33), MI (OR, 10.5; 95% CI, 1.88–59.89), and LOS (OR, 14.79; 95% CI, 8.2–26.67). Multilevel fusion had increased risk of TBE (OR, 5.64; 95% CI, 1.15–27.6), surgical site infection (OR, 16.29; 95% CI, 3.34–79.49), MI (OR, 10.84; 95% CI, 2.01–58.55), LOS (OR, 26.56; 95% CI, 11.8–59.78), and mortality (OR, 10.24; 95% CI, 2.45–42.71). Patients who had anterior cervical discectomy and fusion surgery and received a transfusion had an increased risk of TBE (OR, 4.87; 95% CI, 1.04–22.82), surgical site infection (OR, 9.73; 95% CI, 2.14–44.1), MI (OR, 9.88; 95% CI, 1.87–52.2), increased LOS of more than 2 days (OR, 28.34; 95% CI, 13.79–58.21) and increase in mortality (OR, 6.3; 95% CI, 1.76–22.48). While, transfused patients who had posterior fusion surgery had increased risk of MI (OR, 10.45; 95% CI, 1.42–77.12) and increased LOS of more than 6 days (OR, 4.42; 95% CI, 2.68–7.29).ConclusionsOur results demonstrate that although cervical fusions can be done as outpatient procedures special precautions and investigations should be done for patients who receive transfusion after cervical fusion. These patients are demonstrated to have higher rate of MI, TBE, wound infection and mortality when compared to those who do not receive transfusion.

Risk factors for venous thromboembolism following spinal surgery

“…Five studies [ 11 , 25 , 27 , 29 , 33 ] including 72,493 patients assessed the relationship between a blood transfusion and the incidence of VTE. As 1 study [ 33 ] included the patients undergoing lumbar and thoracic fusion surgery, another study [ 29 ] included patients undergoing cervical fusion surgery, subgroup analysis was performed according to the surgery site. The pooled data revealed that a blood transfusion remarkably increased the incidence of VTE (OR 4.050, 95% CI 2.825–5.805; P < .001).…”

“…These results were in line with previous studies. [ 11 , 27 , 29 , 33 ] Three studies [ 11 , 27 , 33 ] observed a relationship between postoperative transfusion and the incidence of VTE in patients who had undergone lumbar spinal surgery. Aoude et al [ 33 ] retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients who underwent lumbar or thoracic fusion.…”

“…In 2016, they reported that patients receiving transfusions who underwent lumbar fusion were more likely to develop VTE, which was in line with the other 2 studies, [ 11 , 27 ] while there was no increased risk of VTE in patients receiving transfusions who underwent thoracic fusion. Again, Aoude et al [ 29 ] identified 11,588 patients who had cervical fusion from the ACS-NSQIP database. Their results suggested that all transfused patients had an increased risk of VTE.…”

Quality and Safety Improvement in Spine Surgery

“…Currently, numerous other investigators have further carried the clinical inquiry and geared the prediction model development toward other clinical outcomes of interest. [89][90][91][92][93][94][95] Additionally, other teams have extended their investigations to other patient populations more representative of their local settings. 22,[96][97][98][99][100] With the rise of contemporary value-based bundled health care models, interest in cost improvement strategies that do not compromise the quality of care have also led to the development of predictive models to estimate prolonged hospital stay and adverse discharge destination for elective spine surgery.…”

“…132 Today, the high-quality data have appealed to numerous investigators and attracted a wide range of spine-related studies primarily focused on surgical outcomes, adverse events, as well as predictive modeling. [88][89][90][91][92][93][94][95]101,109,[134][135][136] A recent systematic review conducted by Marjoua et al 137 found 40 spinespecific peer-reviewed publications based on the NSQIP data between 2010 and 2015. While the magnitude and quality of data have proven the compelling research merit of NSQIP, the success of the program in improving surgical care owes to the fact that it stands as a national standard to which individual institution can compare their performance.…”