Albumin level predicted complication risk after surgery for vertebral compression fracture
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Patients with an acute osteoporotic vertebral compression fracture and hypoalbuminemia based on preoperative serum albumin levels were statistically more likely to develop major complications, such as sepsis, septic shock, pulmonary embolism, reintubation and prolonged intubation, according to study results.
“As far as minor complications and major complications, we saw there was a dramatic increase in both. That actually correlated with the level, if you will, of malnourishment, so that mildly malnourished patients saw a statically significant increase in both minor and major complications,” study author Stuart H. Hershman, MD, told Healio Orthopedics.
Hershman and his colleagues retrospectively studied 1,979 patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2007 to 2014 that met inclusion criteria of having a surgical intervention for an osteoporotic vertebral compression fracture (OVCF). Researchers subcategorized patients into four groups based on preoperative nutritional status as defined by albumin levels to perform the analysis. They used minor and major postoperative complications, mortality, all-cause 30-day readmission, 30-day readmission related to OVCF and total length of hospital stay for the outcome measures.
The analyses Hershman and colleagues performed, which included analysis of variance, Spearman’s rank correlation coefficient, Chi-square trends and Kruskal-Wallis analyses,
showed a statistically significant decline in patients’ functional status when correlated with preoperative albumin levels.
According to the abstract, sepsis, septic shock, pulmonary embolism, reintubation, prolonged intubation and major complications, in general, were statistically more likely to occur in patients with hypoalbuminemia. Surgical site complications were the only minor complication that failed to demonstrate a statistical correlation with nutritional status, and researchers identified no statistically significant associations between postoperative outcomes and patient age, sex or BMI.
Discussing findings for patients with different levels of preoperative albumin, Hershman said, “Once you got to the severe[ly] malnourished patients, all of a sudden you saw a really big increase in the number of minor and major complications. It just sort of speaks to their medical reserve, meaning how much they have to kind of ‘fight the good fight,’ if you will. These malnourished patients really do not have a lot of physiologic reserve and, because of that, they are at significant risk for these medical complications following, probably any, surgical procedure.”
Researchers noted in the abstract preoperative albumin levels may be good prognostic indicators for adverse outcomes after surgical treatment of OVCFs. Clinically, these levels may be useful as markers for medical frailty, they added.
“We need to be optimizing these patients better,” Hershman said.
He said the increase in complications among patients with higher levels of hypoalbuminemia whose malnutrition was worse was consistent with what the researchers thought. However, they were surprised they did not identify more patients in the cohort with renal issues.
Editor's Note: This article was updated on June 19, 2020, to modify the original headline for clarity.
Perspective
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Owoicho Adogwa, MD, MPH
Every day, 10,000 people turn 65 years old. With an aging population comes associated increases in age-related disorders of the spine, such as osteoporotic vertebral compression fractures. These fractures appear to be more frequent in nutritionally deficient post-menopausal women. Albumin is a proxy for overall nutritional status, with low preoperative levels associated with a higher incidence of postoperative adverse events. Numerous studies, including some by our group, demonstrated an association between low serum albumin levels and higher postoperative complication rates, as well as 30-day hospital readmission rates; corroborating the findings of Hershman and colleagues.
However, the current study requires more rigorous statistical analysis. For instance, the authors need to expand on the inclusion criteria and the patient population. More information is needed about the regression model and if any post-estimation tests were conducted. As these large databases lack patient-level granularity, sensitivity testing with both propensity matching and logistic regression is important to confirm the observed measures of association reported in this paper.
Nonetheless, the findings of this manuscript are important and highlight the need for nutritional optimization prior to spine surgery.
University of Texas Southwestern Medical School
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Gupta A, et al. ePaper 586. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 24-28, 2020 (meeting canceled).
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