Nutritional Status as an Adjunct Risk Factor for Early Postoperative Complications Following Posterior Cervical Fusion

Nathan J. Lee, BS; Parth Kothari, BS; Jun S. Kim, MD; Kevin Phan, BS; John Di Capua, MHS; John Shin, BS; Samuel K. Cho, MD


Spine. 2017;42(18):1367-1374. 

In This Article

Abstract and Introduction


Study Design. Retrospective study on prospectively collected data.

Objective. The aim of this study was to study the impact of nutritional status, as measured by serum albumin level, on patient outcomes following posterior cervical fusion (PCF) surgery.

Summary of Background Data. Malnutrition is a potential modifiable risk factor that has garnered an increasing amount of attention within orthopedics in recent years. There is evidence to suggest the role of nutritional status in lumbar and ACDF surgery, yet the data for PCF are still lacking.

Methods. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was queried by current procedure terminology (CPT) from 2010 to 2014. Bivariate analyses were performed to compare the preoperative characteristics between those with normal albumin and hypoalbuminemia. Postoperative complications and outcomes were similarly analyzed for those with and without low albumin levels. Stepwise multivariate logistic regression models were employed to determine whether hypoalbuminemia was an independent risk factor for short-term patient outcomes and complications.

Results. There were 1573 cases with measured albumin levels (42.4%). The mean (standard deviation) serum albumin level was 3.9 (0.6). Among these patients, 265 (16.8%) cases had hypoalbuminemia. The adjusted analyses demonstrated that patients with hypoalbuminemia had a significantly higher risk for length of stay >5 days (odds ratio [OR] = 3.8; 95% confidence interval [CI] = 2.8–5.1; P < 0.0001). In addition, hypoalbuminemia was an independent risk factor for any complications (OR = 2.7; 95% CI = 1.9–3.7; P < 0.0001), pulmonary complications (OR = 2.3; 95% CI = 1.2–4.5; P = 0.010), intra/postoperative blood transfusions (OR = 3.2; 95% CI = 2.1–4.9; P < 0.0001), sepsis (OR = 4.0; 95% CI = 1.7–9.2; P = 0.001), and venous thromboemoblism (OR = 3.6; 95% CI = 1.5–8.5; P = 0.004).

Conclusion. These findings implicate that a baseline serum albumin <3.5 g/dL may serve as a valuable prognostic measure for the development of several complications following PCF surgery.

Level of Evidence: 3


Posterior cervical fusion (PCF) is a broad term that describes the posterior union of two or more neck vertebrae into a single section of bone, and is commonly used to mitigate mechanical neck pain, maintain segmental instability, and/or control for cervical kyphosis. Despite the utility of PCF, it is not without risks. Complications have been reported to include infection, nerve damage, pseudoarthrosis, thrombophlebitis, problems with anesthesia, and extended hospital stay.[1–7] With the rising incidence of PCF and complication rates being reported to be as high as 15%, an investigation on potential modifiable risk factors is warranted.[8–10]

Malnutrition is one such factor that has garnered an increasing amount of attention within orthopedics in recent years.[11–16] The specific mechanisms by which malnutrition affects outcomes is not entirely clear. It is thought that an adequate caloric balance is required to negate the nutritional demands of surgery, and a depleted state impairs wound healing and prolongs inflammation.[16,17] This appears to be particularly important for spinal fusion surgery. Recently, Bohl et al[18] found that posterior lumbar fusion cases with impaired nutritional states had a higher risk for wound infection, urinary tract infection (UTI), unplanned hospital readmission, and extended inpatient stay than those with normal nutritional states. In another retrospective study, Fu et al[19] demonstrated that preoperative nutritional status was an independent risk factor for postoperative pulmonary and cardiac complications, reoperation, and longer length of stay in patients undergoing anterior cervical discectomy and fusion (ACDF). Although there is strong evidence to support the role of nutritional status in lumbar and ACDF surgery, the data for PCF are still lacking.

Serum albumin concentration is a recognized parameter of malnutrition.[16] The general consensus for defining hypoalbuminemia is an albumin level <3.5 g/dL.[20,21] Using these criteria, this study aimed to determine the effect of low preoperative serum albumin concentration on early postoperative complications and outcomes following PCF.