Why Didn't You Walk Yesterday? Factors Associated With Slow Early Recovery After Adult Spinal Deformity Surgery

Abstract

Study design: This is a retrospective case-control study.

Objectives: The objectives of this study are to identify (1) risk factors for delayed ambulation following adult spinal deformity (ASD) surgery and (2) complications associated with delayed ambulation.

Methods: One-hundred and ninety-one patients with ASD who underwent posterior-only fusion (≥5 levels, LIV pelvis) were reviewed. Patients who ambulated with physical therapy (PT) on POD2 or later (LateAmb, n = 49) were propensity matched 1:1 to patients who ambulated on POD0-1 (NmlAmb, n = 49) based on the extent of fusion and surgical invasiveness score (ASD-S). Risk factors, as well as inpatient medical complications were compared. Logistic regressions were used to identify risk factors for late ambulation.

Results: Of the patients who did not ambulate on POD0-1, 32% declined participation secondary to pain or dizziness/fatigue, while 68% were restricted from participation by PT/nursing due to fatigue, inability to follow commands, nausea/dizziness, pain, or hypotension. Logistic regression showed that intraoperative estimated blood loss (EBL) >2L (OR = 5.57 [1.51-20.55], P = .010) was independently associated with an increased risk of delayed ambulation, with a 1.25 times higher risk for every 250 mL increase in EBL (P = .014). Modified 5-Item Frailty Index (mFI-5) was also independently associated with delayed ambulation (OR = 2.53 [1.14-5.63], P = .023). LateAmb demonstrated a higher hospital LOS (8.4 ± 4.0 vs 6.2 ± 2.6, P < .001). The LateAmb group trended toward an increase in medical complications on POD3+ (14.3% vs 26.5%, P = .210).

Conclusions: EBL demonstrates a dose-response relationship with risk for delayed ambulation. Delayed ambulation increases LOS and may impact medical complications.

Keywords: adult spinal deformity; ambulation; blood loss; delayed; spinal fusion.

Figure 1.

Clinical vignettes comparing early and delayed ambulators. The early ambulator shown in Panel 1 was a 65 year-old female with adult idiopathic scoliosis. She underwent a T2-pelvis posterior spinal fusion with osteotomies from L1-L4 and bilateral iliac fixation. Her intraoperative EBL was 900cc. She ambulated well on POD1 (15’) and POD2 (20’), and rapidly increased her ambulation thereafter. The delayed ambulator shown in Panel 2 was a 57 year-old female fixed thoracolumbar kyphosis and lateral listhesis from L1-5. She underwent a T2-pelvis posterior spinal fusion with Ponte osteotomies from T12 to L4 and bilateral iliac fixation. Her intraoperative EBL was 1800cc. She ambulated on POD2 (4’) and made slow ambulatory progress on POD3 (6’) and POD4 (6’) due to nausea and pain. Due to multiple failed trials of void, she required Foley catheter re-insertion and was discharged with a Foley in place.