New evidence-based guidelines covering five key perioperative spine assessments were issued recently by the Congress of Neurological Surgeons.
The guidelines, published in the medical journal Neurosurgery, provide insight on the following:
- Preoperative osteoporosis assessment
- Preoperative nutritional assessment
- Preoperative pulmonary evaluation and optimization
- Preoperative opioid evaluation
- Preoperative surgical risk assessment
A team of eight physicians from around the country, including John R. Dimar, M.D., spine surgeon with Norton Leatherman Spine, collaborated on the new guidelines. Dr. Dimar was the lead author for the osteoporosis assessment.
The new guidelines provide clarity in areas where previously no recommendations had existed, guidance was unclear or standardized treatment algorithms didn’t exist.
READ MORE: New guidelines for bone health assessment before elective spinal reconstruction
Preoperative osteoporosis assessment
The authors, led by Dr. Dimar, concluded:
This evidence-based clinical guideline provides a recommendation that patients with suspected osteoporosis undergo preoperative assessment and be appropriately counseled about the risk of postoperative adverse events if osteoporosis is confirmed. In addition, preoperative optimization of bone mineral density with select treatments improves certain patient outcomes.
Preoperative nutritional assessment
The authors, including Dr. Dimar and led by Erica F. Bisson, M.D., at the Clinical Neurosciences Center, University of Utah Health in Salt Lake City, concluded:
It is recommended to assess nutritional status using either serum albumin or prealbumin preoperatively in patients undergoing spine surgery.
Preoperative pulmonary evaluation and optimization
The authors, including Dr. Dimar and led by Basma Mohamed, MBChB, Department of Anesthesiology, University of Florida College of Medicine in Gainesville, concluded:
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There is substantial evidence for multiple preoperative patient factors that predict an increased risk of a postoperative pulmonary adverse event. Individuals with these risk factors (functional dependence, advanced age [age 65 or older], chronic obstructive pulmonary disease, congestive heart failure, weight loss and obstructive sleep apnea) who are undergoing spine surgery should be counseled regarding the potential increased risk of a perioperative and postoperative pulmonary adverse events. There is insufficient evidence to support any specific preoperative diagnostic test for predicting the risk of postoperative pulmonary adverse events or any treatment intervention that reduces risk. It is suggested, however, to consider appropriate preoperative pulmonary diagnostic testing and treatment to address active pulmonary symptoms of existing or suspected disease.
Preoperative opioid evaluation
The authors, including Dr. Dimar and led by Marjorie C. Wang, M.D., at the Department of Neurosurgery, Medical College of Wisconsin in Wauwatosa, concluded:
This evidence-based clinical guideline provides Grade B recommendations that preoperative opioid use and longer duration of preoperative opioid use are associated with chronic postoperative opioid use and worse outcome after spine surgery. Insufficient evidence supports the efficacy of an opioid wean before spine surgery (Grade I).
Preoperative surgical risk assessment
The authors, including Dr. Dimar and led by James S. Harrop, M.D., at the Department of Neurological Surgery and Department of Orthopedic Surgery, Thomas Jefferson University, Division of Spine and Peripheral Nerve Surgery, Regional Spinal Cord Injury Center of the Delaware Valley in Philadelphia, Pennsylvania, concluded:
This evidence-based guideline provides a Grade B recommendation that diabetic individuals undergoing spine surgery should have a preoperative hemoglobin A1c test before surgery. They should be counseled regarding the increased risk of reoperation or infection if the level is greater than 7.5 mg/dL. There is conflicting evidence that body mass index correlates with a greater rate of surgical site infections or reoperation rate (Grade I). Smoking is associated with increased risk of reoperation (Grade B) in patients undergoing spinal fusion.