Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women's Hospital-Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
Spine J. 2019 Jan;19(1):144-156. doi: 10.1016/j.spinee.2018.05.037. Epub 2018 Jun 1.
Postoperative morbidity may offset the potential benefits of surgical treatment for spine metastatic disease; hence, risk factors for postoperative complications and reoperations should be taken into considerations during surgical decision-making. In addition, it remains unknown whether complications and reoperations shorten these patients' survival.
We aimed to describe and identify factors associated with having a complication within 30 days of index surgery as well as factors associated with having a subsequent reoperation. Furthermore, we assessed the effect of 30-day complications and reoperations on the patients' postoperative survival, as well as described neurologic changes after surgery.
Retrospective cohort study.
We included 647 patients 18 years and older who had surgery for metastatic disease in the spine between January 2002 and January 2014 in one of two affiliated tertiary care centers.
Our primary outcomes were complications within 30 days after surgery and reoperations until final follow-up or death.
We used multivariate logistic regression to identify risk factors for 30-day complications and reoperations. We used the Cox regression analysis to assess the effect of postoperative complications and reoperations on survival.
From 647 included patients, 205 (32%) had a complication within 30 days. The following variables were independently associated with 30-day complications: lower albumin levels (odds ratio [OR]: 0.69, 95% confidence interval [CI]=0.49-0.96, p=.021), additional comorbidities (OR=1.42, 95% CI=1.00-2.01, p=.048), pathologic fracture (OR=1.41, 95% CI=0.97-2.05, p=.031), three or more spine levels operated upon (OR=1.64, 95% CI=1.02-2.64, p=.027), and combined surgical approach (OR=2.44, 95% CI=1.06-5.60, p=.036). One hundred and fifteen patients (18%) had at least one reoperation after the initial surgery; prior radiotherapy (OR=1.56, 95% CI=1.07-2.29, p=.021) to the spinal tumor was independently associated with reoperation. 30-day complications were associated with worse survival (hazard ratio [HR]=1.40, 95% CI=1.17-1.68, p<.001), and reoperation was not significantly associated with worse survival (HR=0.80, 95% CI=0.09-1.00, p=.054). Neurologic status worsened in 42 (6.7%), remained stable in 445 (71%), and improved in 140 (22%) patients after surgery.
Three or more spine levels operated upon and prior radiotherapy should prompt consideration of a preoperative plastic surgery consultation regarding soft tissue coverage. Furthermore, if time allows, aggressive nutritional supplementation should be considered for patient with low preoperative serum albumin levels. Surgeons should be aware of the increase in complications in patients presenting with pathologic fracture, undergoing a combined approach, and with any additional preoperative comorbidities. Importantly, 30-day complications were associated with worsened survival.
术后发病率可能会抵消脊柱转移瘤手术治疗的潜在益处；因此，在进行手术决策时，应考虑术后并发症和再次手术的风险因素。此外，目前尚不清楚并发症和再次手术是否会缩短这些患者的生存时间。
本研究旨在描述并确定索引手术后 30 天内发生并发症的相关因素，以及与再次手术相关的因素。此外，我们评估了 30 天内并发症和再次手术对患者术后生存的影响，并描述了手术后的神经变化。
回顾性队列研究。
我们纳入了 2002 年 1 月至 2014 年 1 月期间在两个附属三级护理中心之一接受脊柱转移瘤手术的 647 名 18 岁及以上的患者。
我们的主要结局是术后 30 天内的并发症和再次手术，直至最终随访或死亡。
我们使用多变量逻辑回归来确定 30 天内并发症和再次手术的风险因素。我们使用 Cox 回归分析来评估术后并发症和再次手术对生存的影响。
在纳入的 647 名患者中，205 名（32%）在术后 30 天内发生并发症。以下变量与 30 天内并发症独立相关：低白蛋白水平（比值比 [OR]：0.69，95%置信区间 [CI]=0.49-0.96，p=.021）、额外的合并症（OR=1.42，95% CI=1.00-2.01，p=.048）、病理性骨折（OR=1.41，95% CI=0.97-2.05，p=.031）、手术涉及 3 个或以上脊柱节段（OR=1.64，95% CI=1.02-2.64，p=.027）和联合手术入路（OR=2.44，95% CI=1.06-5.60，p=.036）。115 名患者（18%）在初次手术后至少进行了一次再次手术；脊柱肿瘤的既往放疗（OR=1.56，95% CI=1.07-2.29，p=.021）与再次手术独立相关。30 天内并发症与较差的生存相关（危险比 [HR]=1.40，95% CI=1.17-1.68，p<.001），再次手术与较差的生存无显著相关性（HR=0.80，95% CI=0.09-1.00，p=.054）。术后 42 名（6.7%）患者的神经状态恶化，445 名（71%）患者保持稳定，140 名（22%）患者改善。
手术涉及 3 个或以上脊柱节段和术前放疗应促使考虑术前进行整形手术咨询，以获得软组织覆盖。此外，如果时间允许，应考虑对术前血清白蛋白水平较低的患者进行积极的营养补充。外科医生应该意识到在出现病理性骨折、接受联合入路手术和有任何术前合并症的患者中，并发症的发生率会增加。重要的是，30 天内的并发症与生存恶化有关。
