Tihista Mikel, Gu Alex, Wei Chapman, Weinreb Jeffrey H, Rao Raj D
Department of Orthopedic Surgery, George Washington University, 2300 M St NW, Washington, DC, 20037, USA.
J Clin Orthop Trauma. 2020 Sep-Oct;11(5):921-927. doi: 10.1016/j.jcot.2020.04.010. Epub 2020 Apr 14.
Corticosteroids have a negative impact on the human immune system's ability to function at an optimal level. Studies have shown that patients on long-term corticosteroids have higher infection rates. However, the rates of infection and other complications following lumbar decompression surgery remains under-investigated. The aim of our study was to determine the impact of preoperative long-term corticosteroid usage on acute, 30-day postoperative complications in a subset of patients undergoing lumbar spine decompression surgery, without fusion or instrumentation. We hypothesize that patients on long-term corticosteroids will have higher rates of infection and other postoperative complications after undergoing lumbar decompression surgery of the spine.
A retrospective cohort study was conducted using data collected from the National Surgical Quality Improvement Program database data from 2005 to 2016. Lumbar decompression surgeries, including discectomies, laminectomies, and others were identified using CPT codes. Chi-square analysis was used to evaluate differences among the corticosteroid and non-corticosteroid groups for demographics, preoperative comorbidities, and postoperative complications. Logistic regression analysis was done to determine if long-term corticosteroid use predicts incidence of postoperative infections following adjustment.
26,734 subjects met inclusion criteria. A total of 1044 patients (3.9%) were on long-term corticosteroids prior to surgical intervention, and 25,690 patients (96.1%) were not on long-term corticosteroids. Patients on long-term corticosteroids were more likely to be older (p < 0.001), female (p < 0.001), nonsmokers (p < 0.001), and have a higher American Society of Anesthesiologist class (p < 0.001). Multivariate analysis demonstrated that long-term corticosteroid usage was associated with increased overall complications (odds ratio [OR]: 1.543; p < 0.001), and an independent risk factor for the development of minor complications (OR: 1.808; p < 0.001), urinary tract infection (OR: 2.033; p = 0.002), extended length of stay (OR: 1.244; p = 0.039), thromboembolic complications (OR: 1.919; p = 0.023), and sepsis complications (OR: 2.032; p = 0.024).
Long-term corticosteroid usage is associated with a significant increased risk of acute postoperative complication development, including urinary tract infection, sepsis and septic shock, thromboembolic complications, and extended length of hospital stay, but not with superficial or deep infection in patients undergoing lumbar decompression procedures. Spine surgeons should remain vigilant regarding postoperative complications in patients on long-term corticosteroids, especially as it relates to UTI and propensity to decompensate into sepsis or septic shock. Thromboembolic risk attenuation is also imperative in this patient group during the postoperative period and the surgeon should weigh the risks and benefits of more intensive anticoagulation measures.
皮质类固醇对人体免疫系统的最佳功能有负面影响。研究表明，长期使用皮质类固醇的患者感染率更高。然而，腰椎减压手术后的感染率和其他并发症仍研究不足。我们研究的目的是确定术前长期使用皮质类固醇对一部分接受腰椎减压手术（无融合或内固定）患者术后30天急性并发症的影响。我们假设长期使用皮质类固醇的患者在接受腰椎减压手术后感染率和其他术后并发症会更高。
采用回顾性队列研究，使用2005年至2016年从国家外科质量改进计划数据库收集的数据。使用CPT编码识别腰椎减压手术，包括椎间盘切除术、椎板切除术等。采用卡方分析评估皮质类固醇组和非皮质类固醇组在人口统计学、术前合并症和术后并发症方面的差异。进行逻辑回归分析以确定长期使用皮质类固醇在调整后是否可预测术后感染的发生率。
26734名受试者符合纳入标准。共有1044名患者（3.9%）在手术干预前长期使用皮质类固醇，25690名患者（96.1%）未长期使用皮质类固醇。长期使用皮质类固醇的患者更可能年龄较大（p<0.001）、为女性（p<0.001）、不吸烟（p<0.001）且美国麻醉医师协会分级较高（p<0.001）。多变量分析表明，长期使用皮质类固醇与总体并发症增加相关（优势比[OR]：1.543；p<0.001），是发生轻微并发症（OR：1.808；p<0.001）、尿路感染（OR：2.033；p = 0.002）、住院时间延长（OR：1.244；p = 0.039）、血栓栓塞并发症（OR：1.919；p = 0.023）和脓毒症并发症（OR：2.032；p = 0.024）的独立危险因素。
长期使用皮质类固醇与术后急性并发症发生风险显著增加相关，包括尿路感染、脓毒症和感染性休克、血栓栓塞并发症以及住院时间延长，但与接受腰椎减压手术患者的浅表或深部感染无关。脊柱外科医生应密切关注长期使用皮质类固醇患者的术后并发症，尤其是与尿路感染以及发展为脓毒症或感染性休克倾向相关的并发症。在术后期间，对该患者群体进行血栓栓塞风险的降低也至关重要，外科医生应权衡更强化抗凝措施的风险和益处。
