Clinical Neurology and Neurosurgery 126 (2014) 137–142
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Constipation after thoraco-lumbar fusion surgery Martin N. Stienen a,∗ , Nicolas R. Smoll b , Gerhard Hildebrandt a , Karl Schaller c , Enrico Tessitore c , Oliver P. Gautschi c a b c
Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland Frankston Hospital, Department of Surgery, Melbourne, Australia Department of Neurosurgery and Faculty of Medicine, University Hospital Geneva, Geneva, Switzerland
a r t i c l e
i n f o
Article history: Received 14 June 2014 Received in revised form 25 August 2014 Accepted 31 August 2014 Available online 8 September 2014 Keywords: Gastrointestinal morbidity Lumbar fusion surgery Constipation Bowel movement Outcome
a b s t r a c t Background: Thoraco-lumbar posterior fusion surgery is a frequent procedure used for patients with spinal instability due to tumor, trauma or degenerative disease. In the perioperative phase, many patients may experience vomiting, bowel irritation, constipation, or may even show symptoms of adynamic ileus possibly due to immobilization and high doses of opioid analgesics and narcotics administered during and after surgery. Methods: Retrospective single-center study on patients undergoing thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability in 2012. Study groups were built according to presence/absence of postoperative constipation, with postoperative constipation being defined as no bowel movement on postoperative days 0–2. Results: Ninety-nine patients (39 males, 60 females) with a mean age of 57.1 ± 17.3 years were analyzed, of which 44 patients with similar age, gender, BMI and ASA-grades showed constipation (44.4%). Occurrence of constipation was associated with longer mean operation times (247 ± 62 vs. 214 ± 71 min; p = 0.012), higher estimated blood loss (545 ± 316 vs. 375 ± 332 ml; p < 0.001), and higher mean morphine dosages in the postoperative days 0–7 (the difference being significant on postoperative days 1 (48 mg vs. 30.9 mg, p = 0.041) and 2 (43.2 mg vs. 29.1 mg, p = 0.028). The equivalence dose of morphine administered during surgery was similar (339 ± 196 vs. 285 ± 144 mg; p = 0.286). The use of laxatives in the postoperative days 0–7 was generally high in both study groups, while it was more frequent in patients experiencing constipation. One patient with constipation developed a sonographically confirmed paralytic ileus. Patients with constipation showed a tendency toward longer postoperative hospitalization (7.6 vs. 6.7 days, p = 0.136). Conclusions: The rate of constipation was high after thoraco-lumbar fusion surgery. Moreover, it was associated with longer surgery time, higher blood loss, and higher postoperative morphine doses. Further trials are needed to prove if the introduction of faster and less invasive surgery techniques may have a positive side effect on bowel movement after spine surgery as they may reduce operation times, blood loss and postoperative morphine use. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Thoraco-lumbar fusion surgery is a frequent procedure used for patients with spinal instability due to trauma or degenerative disease. Even though the literature regarding gastrointestinal morbidity after spine surgery is scarce, a significant amount of patients experience vomiting, bowel irritation, constipation, or
∗ Corresponding author. Tel.: +41 0 71 494 1111; fax: +41 0 71 494 2883. E-mail address: [email protected] (M.N. Stienen). http://dx.doi.org/10.1016/j.clineuro.2014.08.036 0303-8467/© 2014 Elsevier B.V. All rights reserved.
may even show symptoms of adynamic ileus in the postoperative period, despite generous use of laxatives [1–4]. In a retrospective review of 253 spinal procedures in children, the incidence of postoperative gastrointestinal morbidity was reported to be 77.9%, including emesis (50.6%) and paralytic ileus (42%) [5]. These frequently encountered complaints are likely to be due to pain-related immobilization, high doses of morphine analgesics and narcotics administered during major spine surgery, as well as pain-related activation of the sympathetic system. In addition, intraoperative irritation of sympathetic splanchnic nerves may contribute to paralytic bowel dysfunction [6]. Adequate analgesia, however, is an essential part of the perioperative management in spine surgery
138
M.N. Stienen et al. / Clinical Neurology and Neurosurgery 126 (2014) 137–142
and the use of morphine is often unavoidable. Constipation as frequent side effect of morphine therapy is well known by most physicians and nursing staff [2,7]. Despite timely and adequate prevention, constipation is common on the neurosurgical wards [3,4,8,9]. It has been our observation that the rate of constipation was higher in patients with spinal surgeries than with cranial surgeries. Indeed spinal surgery increased the risk of postoperative gastrointestinal morbidity in a previously published study [5]. In our clinical practice, a considerable number of patients rate their postoperative bowel dysfunction, especially constipation, as more restrictive than the functional restriction from postoperative pain. This striking impact of constipation on the subjective well-being of our patients prompted us to undertake the current study, determine the rate of constipation after thoraco-lumbar spinal fusion surgery and identify factors associated with it. We hypothesize that constipation is common amongst patients receiving thoracolumbar spinal fusion surgery and that the complexity and length of surgery are important predisposing factors.
2. Methods Patient data was retrospectively collected from all patients undergoing thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability at the Department of Neurosurgery of the Kantonsspital St. Gallen in 2012. Informed consent was obtained from all patients. All clinical charts were reviewed. In order to capture the gastrointestinal parameters accurately, we reviewed the nursing records as well. Our nursing staff keep detailed daily records on intake and output, including bowel dysfunction, constipation, as well as kind and frequency of laxatives or enema administered. This data is frequently referred by the clinical team and is generally accurate due to excellent record keeping by our well-trained nursing staff. The following parameters were recorded: patient characteristics (e.g. age, gender, body mass index (BMI), perioperative use and dosage of opioids or laxatives, date of last bowel movement before surgery), anesthesia-related factors (e.g. ASA-grade, type of anesthesia, type and amount of drugs administered during surgery), surgery-related factors (e.g. type and length of surgery, estimated blood loss (EBL)), postoperative course (e.g. surgery-related complications, daily equivalent dose of morphine intake, daily type and amount of laxative intake, need for enema, length of hospitalization), gastrointestinal factors (e.g. date of first gas passage, date of first bowel movement, vomiting). As international consensus on this subject is missing, for this study purpose constipation was defined as no bowel movement on postoperative days 0–2. Study groups were subsequently built according to presence (constipation group) or absence (nonconstipation group) of postoperative constipation. The rationale for choosing postoperative days 0–2 for this approach is discussed below. Concerning the protocol used at our institution, we follow a strict standard including pre-operative bowel preparation in patients operated via an anterior approach to the lumbar spine. In contrary, all patients receiving thoraco-lumbar (non-)instrumented spine surgery using a dorsal or dorsolateral approach are asked on a day-to-day basis about bowel movements and whether they wish to use laxatives. The physicians and nurse staff give recommendations that are usually followed by the patient. Statistical analysis was performed using the chi-square method, the Fisher’s exact test, or the Mann–Whitney-test as appropriate. The software used for statistical analysis was Graphpad Prism 6.0e
Table 1 Baseline patient data of patients with (n = 44) and without postoperative constipation following thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability.
Age (in years; mean ± SD) Gender Male Female BMI (in kg/m2 ) ASA grade 1–2 ≥3 Preoperative daily morphine intake Yes No ED of daily morphine intake (in mg) Preoperative daily laxative intake Yes No
Constipation (n = 44)
No constipation (n = 55)
p-Value
58.0 ± 15.6
60.0 ± 13.1
0.714$
15 (34%) 29 (66%) 27.4 ± 5.6
24 (44%) 31 (56%) 26.6 ± 4.0
0.409◦
34 (77%) 10 (23%)
47 (85%) 8 (15%)
0.432ˆ
17 (39%) 27 (61%) 84.4 ± 120.6
16 (29%) 39 (71%) 76.3 ± 121.6
0.392◦
11 (25%) 33 (75%)
11 (20%) 44 (80%)
0.667$
0.363$
0.629◦
ASA—American Society of Anesthesiologists; BMI—body mass index; ED—equivalent dose. ◦ Two-tailed chi2 -test was performed. ˆ Two-tailed Fisher exact test was performed. $ Mann–Whitney test was used.
for Macintosh computers. Differences were considered significant at p < 0.05. 3. Results Ninety-nine patients (39 males, 60 females) with a mean age of 57.1 ± 17.3 years were analyzed. Forty-four patients (44.4%) with matchable age, gender, ASA-grade, BMI, as well as preoperative morphine and laxative intake showed constipation (Table 1). Indications for surgery and surgery-related parameters are depicted in Table 2. In most cases, posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) procedures were performed, however—in each one patient with or without postoperative constipation, the surgery was performed by an anterior (extra peritoneal) approach. Patients who showed constipation postoperatively were subject to longer surgical procedures (247 ± 62 vs. 214 ± 71 min.; p = 0.012) with higher EBL (545 ± 316 vs. 375 ± 332 ml, p < 0.001; Table 2). Type of anesthesia was equivalent and the amount of morphine derivates administered during surgery was slightly higher in the group of patients with constipation, yet insignificant (Table 3). Six patients with constipation and 4 patients without constipation used a patient-controlled analgesia (PCA) postoperatively (Table 3). Post-surgery, 20% and 7% of patients with or without constipation experienced vomiting. First gas passage on postoperative days 0 or 1 was noticed significantly more often in patients without constipation (Table 4). Patients who experienced constipation required higher mean morphine dosages during the postoperative days 1 (48 mg vs. 30.9 mg, p = 0.041) and 2 (43.2 mg vs. 29.1 mg, p = 0.028). The mean use of morphine remained higher on postoperative days 0–7, while the difference was insignificant on days 0 and 3–7 (Fig. 1; Table 4). The use of laxatives was generally high in both study groups, while the use of laxatives was more frequent in patients experiencing constipation (the difference being significant on postoperative day 3: 80% vs. 54%, p = 0.011; Fig. 1). A broad variety of laxatives with different mechanisms of action were used by patients from
M.N. Stienen et al. / Clinical Neurology and Neurosurgery 126 (2014) 137–142
139
Fig. 1. Use of morphine and laxatives in patients with (n = 44) and without (n = 55) postoperative constipation (control; dashed lines) following thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability. Black graph, left y-axis: Mean equivalent dose of daily morphine (in mg) administered in patients with and without (dashed line) constipation on postoperative days 0–7. The difference between the groups was significant on postoperative days 1 (48 mg vs. 30.9 mg, p = 0.041) and 2 (43.2 mg vs. 29.1 mg, p = 0.028). Gray graph, right y-axis: Percentage of patients with and without (dashed line) constipation receiving laxatives on postoperative days 0–7. The difference between the groups was significant on day 3 (80% vs. 54%, p = 0.011). PO = postoperative.
both study groups. Patients with constipation required more often an administration of enema (Table 5). Surgical complications in the postoperative course leading to re-operation occurred in 2 patients of each group. Concerning Table 2 Surgery-related factors of patients with (n = 44) and without postoperative constipation following thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability.
Indication for surgery Spondylolisthesis Degenerative disc disease with instability Recurring lumbar disc herniation Adjacent segment degeneration (after fusion) Screw loosening (after fusion)
Constipation (n = 44)
No constipation (n = 55)
p-Value
17 (39%) 14 (32%)
32 (58%) 14 (25%)
0.018◦
5 (11%)
2 (4%)
4 (9%)
7 (13%)
4 (9%)
4. Discussion The present study demonstrates that the rate of constipation is high in patients undergoing thoraco-lumbar fusion surgery for degenerative spinal instability (44%), despite a high percentage of patients ingesting laxatives (a lot of them multiple types (Fig. 1 and Table 5)). Overall, the presence of constipation was associated with longer operation times and higher EBL (Table 2). Our
Table 3 Anesthesia-related factors of patients with (n = 44) and without postoperative constipation following thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability.
0 (0%)
Type of procedure performed TLIF PLIF Other
31 12 1 (LDP)
32 22 1 (ALIF)
0.418ˆ
Number of segments with fusion 1 2 ≥3
27 (61%) 14 (32%) 3 (7%)
43 (78%) 8 (15%) 4 (7%)
0.121ˆ
247 ± 62
214 ± 71
0.012$
545 ± 316
375 ± 332
Contents lists available at ScienceDirect
Clinical Neurology and Neurosurgery journal homepage: www.elsevier.com/locate/clineuro
Constipation after thoraco-lumbar fusion surgery Martin N. Stienen a,∗ , Nicolas R. Smoll b , Gerhard Hildebrandt a , Karl Schaller c , Enrico Tessitore c , Oliver P. Gautschi c a b c
Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland Frankston Hospital, Department of Surgery, Melbourne, Australia Department of Neurosurgery and Faculty of Medicine, University Hospital Geneva, Geneva, Switzerland
a r t i c l e
i n f o
Article history: Received 14 June 2014 Received in revised form 25 August 2014 Accepted 31 August 2014 Available online 8 September 2014 Keywords: Gastrointestinal morbidity Lumbar fusion surgery Constipation Bowel movement Outcome
a b s t r a c t Background: Thoraco-lumbar posterior fusion surgery is a frequent procedure used for patients with spinal instability due to tumor, trauma or degenerative disease. In the perioperative phase, many patients may experience vomiting, bowel irritation, constipation, or may even show symptoms of adynamic ileus possibly due to immobilization and high doses of opioid analgesics and narcotics administered during and after surgery. Methods: Retrospective single-center study on patients undergoing thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability in 2012. Study groups were built according to presence/absence of postoperative constipation, with postoperative constipation being defined as no bowel movement on postoperative days 0–2. Results: Ninety-nine patients (39 males, 60 females) with a mean age of 57.1 ± 17.3 years were analyzed, of which 44 patients with similar age, gender, BMI and ASA-grades showed constipation (44.4%). Occurrence of constipation was associated with longer mean operation times (247 ± 62 vs. 214 ± 71 min; p = 0.012), higher estimated blood loss (545 ± 316 vs. 375 ± 332 ml; p < 0.001), and higher mean morphine dosages in the postoperative days 0–7 (the difference being significant on postoperative days 1 (48 mg vs. 30.9 mg, p = 0.041) and 2 (43.2 mg vs. 29.1 mg, p = 0.028). The equivalence dose of morphine administered during surgery was similar (339 ± 196 vs. 285 ± 144 mg; p = 0.286). The use of laxatives in the postoperative days 0–7 was generally high in both study groups, while it was more frequent in patients experiencing constipation. One patient with constipation developed a sonographically confirmed paralytic ileus. Patients with constipation showed a tendency toward longer postoperative hospitalization (7.6 vs. 6.7 days, p = 0.136). Conclusions: The rate of constipation was high after thoraco-lumbar fusion surgery. Moreover, it was associated with longer surgery time, higher blood loss, and higher postoperative morphine doses. Further trials are needed to prove if the introduction of faster and less invasive surgery techniques may have a positive side effect on bowel movement after spine surgery as they may reduce operation times, blood loss and postoperative morphine use. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Thoraco-lumbar fusion surgery is a frequent procedure used for patients with spinal instability due to trauma or degenerative disease. Even though the literature regarding gastrointestinal morbidity after spine surgery is scarce, a significant amount of patients experience vomiting, bowel irritation, constipation, or
∗ Corresponding author. Tel.: +41 0 71 494 1111; fax: +41 0 71 494 2883. E-mail address: [email protected] (M.N. Stienen). http://dx.doi.org/10.1016/j.clineuro.2014.08.036 0303-8467/© 2014 Elsevier B.V. All rights reserved.
may even show symptoms of adynamic ileus in the postoperative period, despite generous use of laxatives [1–4]. In a retrospective review of 253 spinal procedures in children, the incidence of postoperative gastrointestinal morbidity was reported to be 77.9%, including emesis (50.6%) and paralytic ileus (42%) [5]. These frequently encountered complaints are likely to be due to pain-related immobilization, high doses of morphine analgesics and narcotics administered during major spine surgery, as well as pain-related activation of the sympathetic system. In addition, intraoperative irritation of sympathetic splanchnic nerves may contribute to paralytic bowel dysfunction [6]. Adequate analgesia, however, is an essential part of the perioperative management in spine surgery
138
M.N. Stienen et al. / Clinical Neurology and Neurosurgery 126 (2014) 137–142
and the use of morphine is often unavoidable. Constipation as frequent side effect of morphine therapy is well known by most physicians and nursing staff [2,7]. Despite timely and adequate prevention, constipation is common on the neurosurgical wards [3,4,8,9]. It has been our observation that the rate of constipation was higher in patients with spinal surgeries than with cranial surgeries. Indeed spinal surgery increased the risk of postoperative gastrointestinal morbidity in a previously published study [5]. In our clinical practice, a considerable number of patients rate their postoperative bowel dysfunction, especially constipation, as more restrictive than the functional restriction from postoperative pain. This striking impact of constipation on the subjective well-being of our patients prompted us to undertake the current study, determine the rate of constipation after thoraco-lumbar spinal fusion surgery and identify factors associated with it. We hypothesize that constipation is common amongst patients receiving thoracolumbar spinal fusion surgery and that the complexity and length of surgery are important predisposing factors.
2. Methods Patient data was retrospectively collected from all patients undergoing thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability at the Department of Neurosurgery of the Kantonsspital St. Gallen in 2012. Informed consent was obtained from all patients. All clinical charts were reviewed. In order to capture the gastrointestinal parameters accurately, we reviewed the nursing records as well. Our nursing staff keep detailed daily records on intake and output, including bowel dysfunction, constipation, as well as kind and frequency of laxatives or enema administered. This data is frequently referred by the clinical team and is generally accurate due to excellent record keeping by our well-trained nursing staff. The following parameters were recorded: patient characteristics (e.g. age, gender, body mass index (BMI), perioperative use and dosage of opioids or laxatives, date of last bowel movement before surgery), anesthesia-related factors (e.g. ASA-grade, type of anesthesia, type and amount of drugs administered during surgery), surgery-related factors (e.g. type and length of surgery, estimated blood loss (EBL)), postoperative course (e.g. surgery-related complications, daily equivalent dose of morphine intake, daily type and amount of laxative intake, need for enema, length of hospitalization), gastrointestinal factors (e.g. date of first gas passage, date of first bowel movement, vomiting). As international consensus on this subject is missing, for this study purpose constipation was defined as no bowel movement on postoperative days 0–2. Study groups were subsequently built according to presence (constipation group) or absence (nonconstipation group) of postoperative constipation. The rationale for choosing postoperative days 0–2 for this approach is discussed below. Concerning the protocol used at our institution, we follow a strict standard including pre-operative bowel preparation in patients operated via an anterior approach to the lumbar spine. In contrary, all patients receiving thoraco-lumbar (non-)instrumented spine surgery using a dorsal or dorsolateral approach are asked on a day-to-day basis about bowel movements and whether they wish to use laxatives. The physicians and nurse staff give recommendations that are usually followed by the patient. Statistical analysis was performed using the chi-square method, the Fisher’s exact test, or the Mann–Whitney-test as appropriate. The software used for statistical analysis was Graphpad Prism 6.0e
Table 1 Baseline patient data of patients with (n = 44) and without postoperative constipation following thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability.
Age (in years; mean ± SD) Gender Male Female BMI (in kg/m2 ) ASA grade 1–2 ≥3 Preoperative daily morphine intake Yes No ED of daily morphine intake (in mg) Preoperative daily laxative intake Yes No
Constipation (n = 44)
No constipation (n = 55)
p-Value
58.0 ± 15.6
60.0 ± 13.1
0.714$
15 (34%) 29 (66%) 27.4 ± 5.6
24 (44%) 31 (56%) 26.6 ± 4.0
0.409◦
34 (77%) 10 (23%)
47 (85%) 8 (15%)
0.432ˆ
17 (39%) 27 (61%) 84.4 ± 120.6
16 (29%) 39 (71%) 76.3 ± 121.6
0.392◦
11 (25%) 33 (75%)
11 (20%) 44 (80%)
0.667$
0.363$
0.629◦
ASA—American Society of Anesthesiologists; BMI—body mass index; ED—equivalent dose. ◦ Two-tailed chi2 -test was performed. ˆ Two-tailed Fisher exact test was performed. $ Mann–Whitney test was used.
for Macintosh computers. Differences were considered significant at p < 0.05. 3. Results Ninety-nine patients (39 males, 60 females) with a mean age of 57.1 ± 17.3 years were analyzed. Forty-four patients (44.4%) with matchable age, gender, ASA-grade, BMI, as well as preoperative morphine and laxative intake showed constipation (Table 1). Indications for surgery and surgery-related parameters are depicted in Table 2. In most cases, posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) procedures were performed, however—in each one patient with or without postoperative constipation, the surgery was performed by an anterior (extra peritoneal) approach. Patients who showed constipation postoperatively were subject to longer surgical procedures (247 ± 62 vs. 214 ± 71 min.; p = 0.012) with higher EBL (545 ± 316 vs. 375 ± 332 ml, p < 0.001; Table 2). Type of anesthesia was equivalent and the amount of morphine derivates administered during surgery was slightly higher in the group of patients with constipation, yet insignificant (Table 3). Six patients with constipation and 4 patients without constipation used a patient-controlled analgesia (PCA) postoperatively (Table 3). Post-surgery, 20% and 7% of patients with or without constipation experienced vomiting. First gas passage on postoperative days 0 or 1 was noticed significantly more often in patients without constipation (Table 4). Patients who experienced constipation required higher mean morphine dosages during the postoperative days 1 (48 mg vs. 30.9 mg, p = 0.041) and 2 (43.2 mg vs. 29.1 mg, p = 0.028). The mean use of morphine remained higher on postoperative days 0–7, while the difference was insignificant on days 0 and 3–7 (Fig. 1; Table 4). The use of laxatives was generally high in both study groups, while the use of laxatives was more frequent in patients experiencing constipation (the difference being significant on postoperative day 3: 80% vs. 54%, p = 0.011; Fig. 1). A broad variety of laxatives with different mechanisms of action were used by patients from
M.N. Stienen et al. / Clinical Neurology and Neurosurgery 126 (2014) 137–142
139
Fig. 1. Use of morphine and laxatives in patients with (n = 44) and without (n = 55) postoperative constipation (control; dashed lines) following thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability. Black graph, left y-axis: Mean equivalent dose of daily morphine (in mg) administered in patients with and without (dashed line) constipation on postoperative days 0–7. The difference between the groups was significant on postoperative days 1 (48 mg vs. 30.9 mg, p = 0.041) and 2 (43.2 mg vs. 29.1 mg, p = 0.028). Gray graph, right y-axis: Percentage of patients with and without (dashed line) constipation receiving laxatives on postoperative days 0–7. The difference between the groups was significant on day 3 (80% vs. 54%, p = 0.011). PO = postoperative.
both study groups. Patients with constipation required more often an administration of enema (Table 5). Surgical complications in the postoperative course leading to re-operation occurred in 2 patients of each group. Concerning Table 2 Surgery-related factors of patients with (n = 44) and without postoperative constipation following thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability.
Indication for surgery Spondylolisthesis Degenerative disc disease with instability Recurring lumbar disc herniation Adjacent segment degeneration (after fusion) Screw loosening (after fusion)
Constipation (n = 44)
No constipation (n = 55)
p-Value
17 (39%) 14 (32%)
32 (58%) 14 (25%)
0.018◦
5 (11%)
2 (4%)
4 (9%)
7 (13%)
4 (9%)
4. Discussion The present study demonstrates that the rate of constipation is high in patients undergoing thoraco-lumbar fusion surgery for degenerative spinal instability (44%), despite a high percentage of patients ingesting laxatives (a lot of them multiple types (Fig. 1 and Table 5)). Overall, the presence of constipation was associated with longer operation times and higher EBL (Table 2). Our
Table 3 Anesthesia-related factors of patients with (n = 44) and without postoperative constipation following thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability.
0 (0%)
Type of procedure performed TLIF PLIF Other
31 12 1 (LDP)
32 22 1 (ALIF)
0.418ˆ
Number of segments with fusion 1 2 ≥3
27 (61%) 14 (32%) 3 (7%)
43 (78%) 8 (15%) 4 (7%)
0.121ˆ
247 ± 62
214 ± 71
0.012$
545 ± 316
375 ± 332
