Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
Spine J. 2022 Jul;22(7):1149-1159. doi: 10.1016/j.spinee.2022.02.014. Epub 2022 Mar 5.
Diabetes mellitus (DM) is a well-established risk factor for suboptimal outcomes following cervical spine surgery. Hemoglobin A1C (HbA1c), a surrogate for long-term glycemic control, is a valuable assessment tool in diabetic patients.
In patients undergoing elective cervical spine surgery, we sought to identify optimal HbA1c levels to: (1) maximize 1-year postoperative patient-reported outcomes (PROs), and (2) predict the occurrence of medical and surgical complications.
STUDY DESIGN/SETTING: A retrospective cohort study using prospectively collected data was performed in a single academic center.
Diabetic patients undergoing elective anterior cervical fusion and posterior cervical laminectomy and fusion (PCLF) between October 2010-March 2021 were included.
Primary outcomes included Numeric Rating Scale (NRS)-Neck pain, NRS-Arm pain, and Neck Disability Index (NDI). Secondary outcomes included surgical site infection (SSI), complications, readmissions, and reoperations within 90-days postoperatively.
HbA1c, demographic, comorbidity, and perioperative variables were gathered in diabetic patients only. PROs were analyzed as continuous variables and minimum clinically difference (MCID) was set at 30% improvement from baseline.
Of 1992 registry patients undergoing cervical surgery, 408 diabetic patients underwent cervical fusion surgery. Anterior: A total of 259 diabetic patients underwent anterior cervical fusion, 141 of which had an available HbA1c level within one year prior to surgery. Mean age was 55.8±10.1, and mean HbA1c value was 7.2±1.4. HbA1c levels above 6.1 were associated with failure to achieve MCID for NDI (AUC=0.77, 95%CI 0.70-0.84, p<.001), and HbA1c levels above 6.8 may be associated with increased odds of reoperation (AUC=0.61, 95%CI 0.52-0.69, p=.078). Posterior: A total of 149 diabetic patients underwent PCLF, 65 of which had an available HbA1c level within 1 year. Mean age was 63.6±9.2, and mean HbA1c value was 7.2±1.5. Despite a low AUC for NRS-Arm pain and readmission, HbA1c levels above 6.8 may be associated with failure to achieve MCID for NRS-Arm pain (AUC=0.61, 95%CI 0.49-0.73, p=.094), and HbA1c levels above 7.6 may be associated with higher readmission rate (AUC=0.63, 95%CI 0.50-0.75, p=.185).
In a cohort of diabetic patients undergoing elective cervical spine surgery, HbA1c levels above 6.1 were associated with decreased odds of achieving MCID for NDI in anterior cervical fusion surgery. Though only moderate associations were seen for the select outcomes of reoperation (6.8), readmission (7.6), and MCID for NRS-Arm pain (6.8), preoperative optimization of HbA1c using these levels as benchmarks should be considered to reduce the risk of complications and maximize PROs for patients undergoing elective cervical spine surgery.
糖尿病（DM）是颈椎手术后预后不佳的既定危险因素。糖化血红蛋白（HbA1c）是长期血糖控制的替代指标，是糖尿病患者的一种有价值的评估工具。
在接受择期颈椎手术的患者中，我们试图确定最佳的 HbA1c 水平，以：（1）使术后 1 年的患者报告结果（PRO）最大化，（2）预测医疗和手术并发症的发生。
研究设计/地点：在单中心进行了一项前瞻性收集数据的回顾性队列研究。
纳入 2010 年 10 月至 2021 年 3 月期间接受择期前路颈椎融合术和后路颈椎板切除术和融合术（PCLF）的糖尿病患者。
主要结果包括数字评定量表（NRS）-颈部疼痛、NRS-手臂疼痛和颈部残疾指数（NDI）。次要结果包括手术部位感染（SSI）、并发症、90 天内的再入院和再次手术。
仅在糖尿病患者中收集 HbA1c、人口统计学、合并症和围手术期变量。PRO 被分析为连续变量，最小临床差异（MCID）设定为基线的 30%改善。
在接受颈椎手术的 1992 例登记患者中，408 例糖尿病患者接受了颈椎融合手术。前路：共 259 例糖尿病患者接受前路颈椎融合术，其中 141 例在手术前 1 年内有 HbA1c 水平。平均年龄为 55.8±10.1，平均 HbA1c 值为 7.2±1.4。HbA1c 水平高于 6.1 与 NDI 未达到 MCID 相关（AUC=0.77，95%CI 0.70-0.84，p<.001），HbA1c 水平高于 6.8 可能与再次手术的几率增加相关（AUC=0.61，95%CI 0.52-0.69，p=.078）。后路：共 149 例糖尿病患者接受 PCLF，其中 65 例在 1 年内有 HbA1c 水平。平均年龄为 63.6±9.2，平均 HbA1c 值为 7.2±1.5。尽管 NRS-手臂疼痛和再入院的 AUC 较低，但 HbA1c 水平高于 6.8 可能与 NRS-手臂疼痛的 MCID 不达标相关（AUC=0.61，95%CI 0.49-0.73，p=.094），HbA1c 水平高于 7.6 可能与再入院率升高相关（AUC=0.63，95%CI 0.50-0.75，p=.185）。
在接受择期颈椎手术的糖尿病患者队列中，HbA1c 水平高于 6.1 与前路颈椎融合术 NDI 未达到 MCID 的几率降低相关。尽管对于再次手术（6.8）、再入院（7.6）和 NRS-手臂疼痛的 MCID（6.8）等特定结果的相关性仅为中度，但使用这些水平作为基准优化 HbA1c 术前应考虑降低颈椎手术患者并发症风险并使 PRO 最大化。
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