Immediate Postoperative Imaging Following Elective Lumbar Fusion Provides Little Clinical Utility

Andrew A. Ronald, BS; Eric Z. Herring, MD; Christina Gerges, BS; Michael Shost, BS; Tarun Jella, MPH; Martha Sajatovic, MD; Collin M. Labak, MD; Gabriel Smith, MD

Disclosures

Spine. 2021;46(14):958-964. 

In This Article

Abstract and Introduction

Abstract

Study Design: Retrospective review at a single institution of all adult patients who underwent elective lumbar fusion surgery for degenerative spinal disease from 2013 to 2018. Reoperation rates and change in clinical management due to routine imaging findings were the primary outcomes.

Objective: To investigate what effects immediate routine postoperative imaging has on the clinical management of patients following lumbar fusion surgery.

Summary of Background Data: The clinical utility of routine postoperative imaging following lumbar fusion surgery remains uncertain. Existing studies on the clinical utility of postoperative imaging in lumbar fusion patients have largely focused on imaging obtained post-discharge. We present a retrospective analysis that to our knowledge is the first study reporting on the clinical utility of routine imaging in lumbar fusion patients during the immediate postoperative period.

Methods: The medical records of patients who had undergone elective lumbar instrumented fusion for degenerative disease from 2013 to 2018 by neurosurgeons across one regional healthcare system were retrospectively analyzed. Inpatient records and imaging orders for patients were reviewed. Routine immediate postoperative imaging was defined by any lumbar spine imaging prior to discharge in the absence of specific indications.

Results: Analysis identified 115 patients who underwent elective lumbar instrumented fusion for degenerative disease. One-hundred-twelve patients received routine postoperative imaging. Routine imaging was abnormal in four patients (4%). There was one instance (<1%) where routine immediate postoperative imaging led to change in clinical management. Abnormal routine imaging was not associated with either reoperation or development of neurological symptoms postoperatively (P = 0.10), however, new or worsening neurologic deficits did predict reoperation (P < 0.01).

Conclusion: New neurologic deficit was the only significant predictor of reoperation. Routine imaging, whether normal or abnormal, was not found to be associated with reoperation. The practice of routine imaging prior to discharge following elective lumbar fusion surgery appears to provide little utility to clinical management.

Level of Evidence: 3

Introduction

Levels of interest localization and visualizing accurate placement of all hardware remains a gold standard in the care of patients undergoing spinal instrumentation. The benefit of obtaining radiographic images past the index operation during postoperative hospital stay remains contentious among surgeons. In a survey of spine surgeons, 54% indicated they order postoperative imaging after surgery before discharge.[1] Furthermore, the majority ordered routine postoperative imaging even with adequate intraoperative images of the patient's final construct.[1] Evidence suggests there is no detectable movement of implanted hardware in the immediate postoperative period,[2,3] raising doubts on the utility of immediate postoperative imaging, especially in the setting of adequate intraoperative films of the hardware.

An estimated 200,000 elective lumbar fusion surgeries, costing over $10 billion, occurred in the United States in 2015 alone.[4] Routine postoperative care pathway optimization of these patients could improve direct contribution margins and improve patient care across healthcare systems. Moreover, unnecessary imaging is a known cause of radiation exposure and a source of excessive spending in the US healthcare system.[5,6] Understanding the utility of postoperative imaging on patient care may help identify a process improvement for common clinical practice.

Existing studies on the clinical utility of postoperative imaging in asymptomatic spinal fusion patients have largely focused on imaging obtained after hospital discharge. Studies reviewing radiographic surveillance of asymptomatic lumbar fusion patients has found the practice to add little value to surgeons' clinical management.[7–9] Studies investigating the utility of imaging in the immediate postoperative period before hospital discharge are limited to cervical fusion patients and have similarly found little clinical value in the practice.[10,11] To date, there are no published studies specifically investigating routine immediate postoperative imaging for lumbar fusion patients. Our aim was to evaluate the clinical utility of immediate postoperative imaging for all patients who underwent lumbar fusion by neurosurgeons at our institution over a 6 years period.

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