SPINE Volume 39, Number 9, pp E557-E563 ©2014, Lippincott Williams & Wilkins

CERVICAL SPINE

Incidence, Risk Factors, and Outcomes of Postoperative Airway Management After Cervical Spine Surgery Sreeharsha V. Nandyala, BA,* Alejandro Marquez-Lara, MD,* Daniel K. Park, MD,† Hamid Hassanzadeh, MD,* Sriram Sankaranarayanan, MD,* Mohamed Noureldin, MD,* and Kern Singh, MD*

Study Design. Retrospective database analysis. Objective. To identify the incidence and risk factors for a prolonged intubation or an unplanned reintubation after cervical spine surgery (CSS). Summary of Background Data. Patients who undergo CSS occasionally require prolonged mechanical ventilation or an unplanned reintubation for airway support. Despite the potential severity of these complications, there are limited data in the published literature addressing this issue. Methods. The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who underwent a CSS. Patients who required a prolonged intubation more than 48 hours or an unplanned reintubation after CSS were compared with those without airway compromise. Preoperative patient characteristics, intraoperative variables, hospital length of stay, 30-day complication rates, and mortality were compared between the cohorts. An α ≤ 0.001 denoted statistical significance. A multivariate regression model was used to identify independent predictors for a prolonged intubation and an unplanned reintubation. Results. A total of 8648 cervical spine procedures were identified from 2006 to 2011 of which 54 patients (0.62%) required prolonged ventilation and 56 patients (0.64%) underwent a postoperative reintubation. Patients who required postoperative airway management were older and demonstrated a greater comorbidity burden (P < 0.001). In addition, the affected cohorts demonstrated a

From the *Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL; and †Department of Orthopedic Surgery, William Beaumont Hospital, Royal Oak, MI. Acknowledgment date: September 9, 2013. First revision date: December 12, 2013. Second revision date: January 8, 2014. Acceptance date: January 9, 2014. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, consultancy, stock/stock options and royalties. Address correspondence and reprint requests to Kern Singh, MD, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 300, Chicago, IL 60612; E-mail: [email protected] DOI: 10.1097/BRS.0000000000000227 Spine

significantly greater rate of readmissions, reoperations, postoperative complications, and mortality (P < 0.001). Regression analysis identified the independent predictors for prolonged ventilation to include a history of cardiac disease and dialysis along with a low preoperative albumin level (P < 0.05). Similarly, the independent risk factors for a postoperative reintubation included a history of recent weight loss more than 10%, recent operation within 30 days, low preoperative hematocrit, and a high serum creatinine (P < 0.05). Conclusion. Postoperative airway management is a rare complication after CSS. A prolonged intubation and an unplanned reintubation carry a greater rate of postoperative complications and mortality. High-risk patients should be identified prior to surgery to mitigate the risk factors for postoperative airway compromise. Key words: postoperative airway management, respiratory failure, reintubation, prolonged ventilation, cervical spine. Level of Evidence: 3 Spine 2014;39:E557–E563

P

ostoperative pulmonary complications have significant implications on postoperative morbidity and mortality.1–5 Medicare data from 2005 to 2007 demonstrated that postoperative respiratory failure cost an additional $1.82 billion to the Medicare system and carried a mortality rate of 21.8%.6 Some evidence suggests that the rate of postoperative respiratory complications may range from 1.7% to 10% after neck surgery.7 The majority of these reports include small, single institutional studies that evaluated carotid endarterectomy, thyroidectomy, repair of a cleft palate, and other head and neck surgical procedures.7–15 As such, the purpose of this study was to analyze a large, multicenter, population-based database to characterize the incidence and risk factors associated with a prolonged intubation (>48 hr) or an unplanned postoperative reintubation after cervical spine surgery (CSS) in the United States.

MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database collects the risk-adjusted outcomes of surgical procedures.16,17 One hundred thirty-five variables related to the patient demographics, surgical profile, and perioperative data including the 30-day www.spinejournal.com

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CERVICAL SPINE

Airway Management After Cervical Surgery • Nandyala et al

TABLE 1. CPT Coding Cervical Spine Procedure

Primary CPT Codes

Exclusion Codes

Anterior cervical fusion

63075, 22551, or 22554

22856, 22600, 22842, 63015, 63020, 63045, 63051, 63076, 63081, 22552, 22585, 22846

Posterior cervical fusion

22600

63075, 22551, 22554

Posterior cervical decompression

63020 or 63045

63075, 22551, 22554, 22600, 63075, 22551, 22554, 22856, 22600, 22842, 63015, 63020, 63045, 63051, 63076, 63081, 22552, 22585, 22846

CPT indicates Current Procedural Terminology.

TABLE 2. Characteristics of Patients Requiring More Than 48 Hours Mechanical Ventilation After

Cervical Spine Surgery

P

Variable

Control

Prolonged Ventilation

Count (%)

8594

54

54.05 (12.0)

61.69 (12.2)