Preoperative Risk Stratification: Who Needs Medical Consultation?

David S. Casper, MD; Jeffrey A. Rihn, MD

Disclosures

Spine. 2020;45(12):860-861. 

Objective: The purpose of this study is to provide a review of preoperative clearance and optimization, before elective spine surgery.

Summary of Background Data: Patient optimization preceding elective surgery is critical to ensure the best possible outcome.

Methods: Historical and current literature pertaining to patient clearance and optimization, before elective surgery, was reviewed. These data were then synthesized and assessed to provide a balanced view on current trends in regards to preoperative management and optimization.

Results: The American Academy of Cardiology defines spine surgery as "intermediate" risk, and thus patients are permitted to forgo formal cardiac evaluation if they have no active cardiac condition and demonstrate adequate functional capacity; however, those with active or chronic medical conditions require further investigation before elective operations.

Conclusion: Overall, preoperative screening and optimization of comorbidities are vital to ensure positive outcomes in elective spine surgery, and the aforementioned criteria must be considered on an individual basis. Further research into specific preoperative optimization guidelines would help to ensure successful outcomes for those undergoing spine surgery.

In the setting of elective spine surgery, patient risk stratification and preoperative medical optimization are paramount. Medical comorbidities and patient risk factors must be addressed to help decrease postoperative complications, decrease hospital length of stay, and maximize patient outcomes.[1] It is often difficult to determine whether a patient warrants preoperative medical evaluation. Patients without medical conditions that are followed regularly by a general practioner do not require preoperative medical consultation. The American Academy of Cardiology defines spine surgery as "intermediate" risk, and thus patients are permitted to forgo formal cardiac evaluation if they have no active cardiac condition and demonstrate adequate functional capacity (i.e., climbing a flight of stairs).[2] This recommendation is identical for other surgical procedures/patients defined as "intermediate" risk. A cardiologist should evaluate those with active cardiac disease preoperatively. Patients with clinical risk factors for cardiac disease, including chronic kidney disease, diabetes, history of coronary artery disease, or history of previous heart failure, should be evaluated by a medical physician to determine whether cardiology consultation is warranted.[3]

Other common comorbid conditions, in elective spine surgery patients, include chronic obstructive pulmonary disease and asthma.[4] These patients should remain on scheduled medications during the perioperative period. Additionally, 1 week before surgery, preoperative spirometry is indicated to assess whether further bronchodilation or preoperative pulmonology consultation is necessary.[5] Those with severe pulmonary disease, including supplemental oxygen at baseline, should seek pulmonology guidance preoperatively and be counseled on the possibility of prolonged postoperative intubation.[6] Furthermore, all patients should be counseled on smoking cessation, with significant benefits noted with cessation 8 weeks before surgery.[7] Smoking increases the risk of delayed wound healing, infection, and nonunion, and patients drastically decrease the rates of these complications with cessation.[7]

Patients with preexisting coagulopathies should undergo preoperative hematologic screening. Surgical candidates that have undergone previous procedures, including both invasive and noninvasive procedures, such as dental surgery, and have not experienced complications, excessive bleeding, or bruising, are unlikely to have a preexisting hematologic condition, and thus no further workup is necessary.[3]

An additional surgical risk factor is patients with obesity. Morbidly obese patients, defined as a body mass index >40 kg/m2, presenting for elective spine surgery, should undergo counseling on their increased risk of deep vein thrombosis/pulmonary embolism, wrong level surgery (operating on an unintended spinal level), wound infection, and greater blood loss.[3,8] Referral to a nutritionist or bariatric surgeon is recommended for those with a history of weight loss difficulty.[1] Nutrition itself plays a key role, as malnourished or undernourished patients demonstrate higher rates of infection and postoperative complications. Risk factors for malnutrition include previous surgery, gastrointestinal disease, advanced age, recent weight loss, alcohol abuse, and systemic disease.[9] In patients with any of the abovementioned risk factors, preoperative nutrition labs, including albumin, transferrin, CBC, and vitamin D, are indicated. Similar to underweight patients, those who are obese can also be malnourished and should thus undergo screening accordingly.[10]

Overall, preoperative screening and optimization of comorbidities are vital to ensure positive outcomes in elective spine surgery, and the aforementioned criteria must be considered on an individual basis. Further research into specific preoperative optimization guidelines would help to ensure successful outcomes for those undergoing spine surgery.

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