Predictors of Nonelective Surgery for Spinal Metastases

Insights From a National Database

Hammad A. Khan, BS; Nicholas M. Rabah, BS; Vikram Chakravarthy, MD; Raghav Tripathi, MPH; Ajit A. Krishnaney, MD


Spine. 2021;46(24):E1334-E1342. 

In This Article

Abstract and Introduction


Study Design: Secondary analysis of a national all-payer database.

Objective: Our objectives were to identify patient- and hospital-level factors independently associated with the receipt of nonelective surgery and determine whether nonelective surgery portends differences in perioperative outcomes compared to elective surgery for spinal metastases.

Summary of Background Data: Spinal metastases may progress to symptomatic epidural spinal cord compression that warrants urgent surgical intervention. Although nonelective surgery for spinal metastases has been associated with poor postoperative outcomes, literature evaluating disparities in the receipt of nonelective versus elective surgery in this population is lacking.

Methods: The National Inpatient Sample (2012–2015) was queried for patients who underwent surgical intervention for spinal metastases. Multivariable logistic regression models were constructed to evaluate the association of patient- and hospital-level factors with the receipt of nonelective surgery, as well as to evaluate the influence of admission status on perioperative outcomes.

Results: After adjusting for disease-related factors and other baseline covariates, our multivariable logistic regression model revealed several sociodemographic differences in the receipt of nonelective surgery. Patients of black (odds ratio [OR] = 1.38, 95% confidence interval [CI]: 1.03–1.84, P = 0.032) and other race (OR = 1.50, 95% CI: 1.13–1.98, P = 0.005) had greater odds of undergoing nonelective surgery than their white counterparts. Patients of lower income (OR = 1.40, 95% CI: 1.06–1.84, P = 0.019) and public insurance status (OR = 1.56, 95% CI: 1.26–1.93, P < 0.001) were more likely to receive nonelective surgery than higher income and privately insured patients, respectively. Higher comorbidity burden was also associated with greater odds of non-elective admission (OR = 2.94, 95% CI: 2.07–4.16, P< 0.001). With respect to perioperative outcomes, multivariable analysis revealed that patients receiving nonelective surgery were more likely to experience nonroutine discharge (OR = 2.50, 95% CI: 2.09–2.98, P< 0.001) and extended length of stay [LOS] (OR = 2.45, 95% CI: 1.91–3.16, P < 0.001).

Conclusion: The present study demonstrates substantial disparities in the receipt of nonelective surgery across sociodemographic groups and highlights its association with nonroutine discharge and extended LOS.

Level of Evidence: 3


Spinal metastases occur in approximately 40% of patients with cancer, of which nearly 20% progress to symptomatic metastatic epidural spinal cord compression (MESCC).[1,2] Patients presenting with high-grade ESCC may, in the absence of emergent decompression, experience progressive neurologic impairment and eventual paraplegia, whereas those presenting with low-grade ESCC without neurologic compromise may be candidates for elective decompression and subsequent radiation.[3–6] Early screening, identification, and treatment of spinal metastases may help to circumvent the negative sequelae of high-grade ESCC, thereby preserving neurologic function and increasing quality of life.

Although patients with fewer barriers to health care may routinely receive high-quality screening that facilitates earlier surgical intervention for spinal metastases, those with lower health care access and utilization may present emergently at later stages of disease. This premise has precedent in the cancer literature, which demonstrates that patients in minority racial groups are more likely to present with advanced stages of cancer and suffer higher mortality rates, likely as a product of poorer health care access and quality.[7–12] Similar inequities exist in the spine surgery setting, where studies indicate that non-White patients are less likely to receive elective lumbar fusion at high-volume centers and be offered surgical intervention for primary spinal cord tumors.[13,14] Given that emergent surgery for spine tumors has been associated with greater rates of readmission, reoperation, and major postoperative complications compared to elective surgery, elucidating whether such inequities exist with regards to the treatment of spinal metastases is critical in eliminating barriers to timely intervention and improving patient outcomes.[15]

As such, the present study utilized a national all-payer database to identify factors associated with receiving non-elective surgery for spinal metastases, after adjusting for sociodemographic factors, comorbidity burden, hospital characteristics, and disease-specific variables. Additionally, we sought to determine whether nonelective surgery portends differences in perioperative outcomes, such as in-hospital complications, discharge disposition, length of stay (LOS), and total hospital costs compared to elective surgery.