Dr. Venkat Boddapati
According to Venkat Boddapati, MD, a fifth-year resident in the Department of Orthopedic Surgery at NewYork-Presbyterian/
“Patients [are] reporting positive outcomes related to pain reduction and improvement in functional status,” says Dr. Boddapati. “But at the end of the day, as with any surgery, there are risks, and those risks become particularly heightened when you're discussing spine surgery of any kind.”
In the realm of anterior cervical spine surgery – the most common of which are anterior cervical discectomy and fusion, corpectomy, and cervical disc replacement – one of the major complications after surgery, and indeed, the most dreaded, is respiratory compromise, which can lead to catastrophic airway failure and patient mortality. With this in mind, Dr. Boddapati and orthopedic spine surgeons from Och Spine at NewYork-Presbyterian sought to better understand respiratory complications after anterior cervical spine surgery through a large retrospective cohort study. “How often do they occur? Who tends to have these complications? And what can we do to mitigate these risks? Answering these questions was our motivation for conducting this research,” says Dr. Boddapati. “Given how rare respiratory compromise is, you need a well-powered study leveraging big data to answer the types of questions we posed. For our study, we leveraged data from a large national, previously validated registry.”
Whys and Wherefores of Respiratory Compromise
This current study defined respiratory compromise as the failure to wean a patient from the ventilator within 48 hours postoperatively or emergent unplanned reintubations with 30 days after surgery. Prior studies have shown rates of respiratory complications after anterior cervical spine surgery ranging from 0 percent to 6.1 percent. According to Dr. Boddapati, previous studies have, at times, found contradictory predictors for respiratory compromise or lacked a sufficiently large sample size in light of the rarity of this complication.
“The existing literature has conflicting findings between studies with regards to predictors or factors associated with developing respiratory complications after anterior cervical spine surgery,” says Dr. Boddapati. “Conflicting or incomplete findings in the existing literature can cause confusion and make it difficult to truly understand the risks for patients undergoing the more complex anterior cervical spine procedures.”
To address the limitations of this earlier research, the orthopedic spine surgery faculty at NewYork-Presbyterian/
“Our study used one of the largest sample sizes to date to identify independent patient specific and surgical risk factors for developing respiratory compromise so that preoperatively we could better identify, optimize, and counsel patients at high risk,” says Dr. Boddapati. “This would enable us to alert relevant members of the care team to patients at very high risk for respiratory compromise in order to optimize care in a multi-disciplinary manner in conjunction with anesthesia, intensivists, and other members of the care team.”
Our study used one of the largest sample sizes to date to identify independent patient specific and surgical risk factors for developing respiratory compromise so that preoperatively we could better identify, optimize, and counsel patients at high risk.
— Dr. Venkat Boddapati
The study by Dr. Boddapati and his NewYork-Presbyterian/
- Of the 52,270 patients who had an anterior cervical spine surgery, 298 developed respiratory compromise – an incidence rate of 0.57 percent
- Patients who developed respiratory compromise had high rates of 30-day mortality (11.7 percent) and significantly higher rates of total complications (75.8 percent) compared to those who did not (2.66 percent)
- The most common complications were unplanned return to the operating room (43.6 percent), pneumonia (35.9 percent), and sepsis (14.8 percent)
- Primary reasons for reoperations were hematoma evacuation and tracheostomy
- Patients older than 50 had an increased risk for respiratory compromise and patients older than 70 had nearly a fourfold increase for risk
- Other independent patient-specific factors predictive of respiratory compromise were the presence of medical comorbidities, such as cardiac disease and COPD; and preoperative myelopathy. Surgical factors associated with developing respiratory compromise included increasing operative duration and multi-level corpectomies.
The Influence of Operative Duration
Operative duration as a risk factor for respiratory compromise after anterior cervical spine surgery and its effect on perioperative outcomes has been the subject of considerable research. “There are several logical reasons why increasing operative duration can cause respiratory compromise,” explains Dr. Boddapati. “For example, the longer you have open skin and tissues and muscles retracted, the greater the risk that swelling is going to occur in these soft tissues. With anterior cervical spine surgeries, respiratory complications can be related to angioedema in which inflammation of the soft tissues occurs in the anterior neck. In our study, we found that operative duration greater than three hours imparted a 2.3 fold increased risk of developing respiratory compromise after anterior cervical spine surgery..”
Dr. Venkat Boddapati and Dr. Zeeshan Sardar, an orthopedic spin surgeon at Och Spine at NewYork-Presbyterian, perform a three-level anterior cervical spine surgery for cervical myeloradiculopathy
Planning Ahead for Potential Complications
Och Spine at NewYork-Presbyterian is dedicated to patients with spine pathology, where spine specialists from multiple disciplines manage their care preoperatively, intra-operatively, and postoperatively. “Obviously any surgery is not without the risk of complications,” notes Dr. Boddapati. “With spine surgery, those complications are magnified because the risk profile for spine procedures is much higher than for other orthopedic procedures. Our surgeons and providers are cognizant of the appropriate perioperative care that these patients require, including the risks and how they are manifested, so they can take quick and appropriate action. So, for example, preoperatively, for an older male patient with comorbidities, you will want to plan for surgical co-management with anesthesiologists and intensivists and admission of the patient to the hospital (versus an ambulatory procedure).”
“Our anesthesiologists are experts in the field of anesthesia management for patients undergoing spine surgery,” continues Dr. Boddapati. “They are well aware of the risks for complications that these patients can develop and keep a vigilant eye on them in the PACU. Our nursing staff will be aware of patients who are at high risk for respiratory complications and will maintain close observation of these patients and advise other team members as efficiently as possible if the patient is taking a turn for the worse. Availability of specialists in spine care and critical care are extremely important when you take care of any surgical patient, but, in particular, when it is a spine patient.”
Dr. Boddapati and his NewYork-Presbyterian/
