Abstract
Study Design
Retrospective cohort study.
Purpose
To compare rates of 30-day reoperation (RTOR), readmission, overall postoperative complication, non-home discharge, and length of stay (LOS); and investigate individual postoperative complication rates among patients with preoperative normoalbuminemia versus hypoalbuminemia.
Overview of Literature
Evidence continues to accumulate associating poor preoperative nutritional status with inferior surgical outcomes in spinal deformity and oncology. These spinal subspecialities frequently require instrumentation and significant tissue disruption. However, the relationship between preoperative nutrition and shorter, less invasive spinal decompression remains poorly assessed.
Methods
The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify adult patients (>18 years) who underwent elective lumbar laminectomy for lumbar stenosis between 2015 and 2022. Univariate comparison and multivariate logistic regression analyses were conducted.
Results
This study identified 9,593 cases. Among primary outcomes, patients with hypoalbuminemia reported more 30-day readmission (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.17–1.2.82; p=0.008) and non-home discharge rates (OR, 2.08; 95% CI, 1.57–2.76; p<0.001) as well as longer LOS (3.7±4.5 days vs. 1.9±2.4 days, p<0.0005) in both univariate and multivariate analyses, whereas they demonstrated higher RTOR (5.3% vs. 2.7%, p=0.003) and postoperative complication rates (19.0% vs. 5.8%, p<0.001) in only univariate analysis compared with those having normoalbuminemia. Among secondary outcomes, patients with hypoalbuminemia reported statistically more wound and pulmonary complications in univariate analysis; however, they had higher risks of only venous thrombosis requiring anticoagulation and stroke in multivariate analysis.
Conclusions
Preoperative hypoalbuminemia is associated with higher rates of 30-day readmission, non-home discharge, and postoperative complications, as well as longer LOS after elective open lumbar laminectomy. These data indicate the importance of preoperative nutritional optimization even in shorter, more routine spinal surgery.
Keywords: Lumbar, Stenosis, Malnutrition, Elective, Laminectomy
Graphical Abstract
Introduction
Lumbar spinal stenosis is a prevalent condition characterized by spinal canal narrowing, frequently causing neurogenic claudication and functional decline. Degenerative pathologies, including intervertebral disc degeneration, facet joint arthropathy, and ligamentum flavum hypertrophy, resulting in spinal canal narrowing and neural compression, are the leading cause of lumbar spinal stenosis [1,2]. It predominantly affects the aging population and is one of the leading indications for spinal surgery in adults over 65 years of age [2]. Lumbar laminectomy is an extensively administered surgical treatment aimed at decompressing the neural elements and improving symptoms. It remains among the most commonly performed spine procedures in the United States [3]. Patient-level factors, including comorbidities and nutritional status, affect surgical outcomes after lumbar laminectomy despite its routine use. Recent literature has indicated the importance of preoperative nutrition as a modifiable factor affecting outcomes among complex spinal surgeries [4–6].
Preoperative nutritional status, particularly hypoalbuminemia (serum albumin <3.5 g/dL), is increasingly recognized as an important predictor of poor surgical outcomes in complex spine surgery [4,5,7–11]. Studies in spinal deformity have revealed that malnutrition is associated with increased complications, prolonged length of stay (LOS), and higher non-home discharge rates [12,13]. Similarly, in oncologic spine surgery, hypoalbuminemia has been associated with greater risks of wound infection, thromboembolic events, and mortality [14,15]. These procedures frequently involve large exposures, instrumentation, significant blood loss, and extended operative times, magnifying the effect of nutritional deficiencies. However, the association between preoperative nutrition and outcomes in less invasive procedures, such as lumbar decompression without fusion, remains underexplored.
To address this gap in the literature, the present study aims to (1) compare 30-day reoperation rates (RTOR), 30-day readmission, any postoperative complication, and non-home discharge rates, as well as LOS; and (2) investigate individual postoperative complication rates among adult patients who underwent elective open lumbar laminectomy for lumbar stenosis with preoperative normoalbuminemia versus hypoalbuminemia.
Materials and Methods
Ethics statement
An institutional review board approval is not required for this retrospective cohort study, as a large national database containing deidentified patient information is utilized. This manuscript was prepared adhering to STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.
Data collection
All data analyzed were extracted from the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP) database. NSQIP compiled data from over 700 hospitals in the United States, focusing on the 30-day time point. Individuals specifically trained in NSQIP methods and data entries collect and submit patient data. All data is audited to ensure accuracy at regular intervals [16]. NSQIP is the only multiinstitutional, multispecialty, clinically based, prospectively collected quality improvement program for surgical specialties [17]. Many consider NSQIP the most accurate database for surgical outcomes research and have shown to improve surgical outcomes [18].
This study included adult patients over 18 years of age who underwent elective open lumbar laminectomy for lumbar stenosis between 2015 and 2022. The cohort was then categorized into two groups: (1) patients with preoperative normoalbuminemia and (2) those with preoperative hypoalbuminemia. Normoalbuminemia is defined as a serum albumin level of 3.5–5.5 g/dL, whereas hypoalbuminemia is characterized by a serum albumin level of <3.5 g/dL [19,20]. Cases of open lumbar laminectomy for lumbar stenosis were identified using Current Procedural Terminology (CPT) code 63047 for lumbar laminectomy when accompanied by the postoperative diagnosis of lumbar stenosis determined by International Classification of Disease, tenth revision, codes M48.06–M48.062. This study excluded urgent and emergent cases. Further, minimally invasive and endoscopic decompressions were not included within this analysis, as the amount of tissue dissection and operative times when employing these techniques differ from an open approach. Moreover, cases with adjunctive CPT codes indicating associated instrumentation and/or fusion, such as those for arthrodesis (22612–22630, 22551), osteotomies (22206–22226), instrumentation (22840–22870), use of autograft/allograft (20930–20938), and stereotactic navigation (61783), were excluded.
Data organization
Cases were organized into binary outcomes of 30-day readmission (+ or −), RTOR (+ or −), any postoperative complication (+ or −), and non-home discharge (+ or −). Binary variables for individual postoperative complications (i.e., pulmonary embolism [+ or −]) were developed.
Statistical analysis
Univariate and multivariate analyses were both conducted. For univariate comparison analyses, the Mann-Whitney U analysis was performed for continuous variables given non-parametric distribution, whereas a chi-square test was utilized for categorical variables. Covariates from the univariate model, including baseline characteristics, with a p-value of <0.2, were included in a multivariate logistic regression to control for confounding variables. Binary logistic regression analysis was conducted, using normoalbuminemia as the reference group, to calculate odds ratios (OR) and 95% confidence intervals (CIs). Covariates were assessed for collinearity by variance inflation factors (VIF) and considered colinear if the VIF is >10. A Hosmer-Lemeshow goodness-of-fit test was conducted, and the multivariate model was considered a good fit via a non-significant p-value of >0.05. A p-value of <0.05 and 95% CIs not including 1 indicated statistical significance for all analyses. IBM SPSS Statistics ver. 28.0 (IBM Corp., Armonk, NY, USA) was used for all analyses.
Results
This study identified 9,593 total cases (normoalbuminemia, n=9,193; hypoalbuminemia, n=400). Table 1 shows baseline patient characteristics. Table 2 summarizes the univariate comparison analyses for both primary and secondary outcomes. Figs. 1 and 2 illustrate the results of multivariate analyses for primary and secondary outcomes, respectively.
Table 1.
Baseline patient characteristics
| Characteristic | Hypoalbuminemia | Normoalbuminemia | p-value |
|---|---|---|---|
| Total patients | 400 | 9,193 | - |
| Year | 0.55 | ||
| 2015 | 8 (2.0) | 327 (2.6) | |
| 2016 | 53 (13.3) | 1,195 (13.0) | |
| 2017 | 61 (15.3) | 1,348 (14.7) | |
| 2018 | 71 (17.8) | 1,352 (14.7) | |
| 2019 | 66 (16.5) | 1,640 (17.8) | |
| 2020 | 59 (14.8) | 1,271 (13.8) | |
| 2021 | 60 (15.0) | 1,460 (15.9) | |
| 2022 | 22 (5.5) | 690 (7.5) | |
| Age (yr) | <0.001 | ||
| 18–29 | 0 (0.0) | 42 (0.5) | |
| 30–39 | 1 (0.3) | 125 (1.4) | |
| 40–49 | 11 (2.8) | 359 (3.9) | |
| 50–59 | 39 (10.0) | 1,292 (14.1) | |
| 60–69 | 108 (27.6) | 2,931 (32.1) | |
| 70–79 | 138 (35.3) | 3,231 (35.4) | |
| 80–89 | 94 (24.0) | 1,155 (12.6) | |
| Sex | 0.02 | ||
| Male | 230 (57.5) | 5,827 (63.4) | |
| Female | 170 (42.5) | 3,366 (36.6) | |
| Race | 0.07 | ||
| Non-Hispanic White | 293 (76.7) | 7,291 (82.1) | |
| Black | 46 (12.0) | 719 (8.1) | |
| Hispanic | 26 (6.8) | ||
| American Indian or Alaska Native | 2 (0.5) | 62 (0.7) | |
| Native Hawaiian or Other Pacific Islander | 1 (0.3) | 22 (0.2) | |
| Asian | 14 (3.7) | 228 (2.6) | |
| Admission quarter | 0.77 | ||
| 1 | 94 (23.5) | 2,203 (24.0) | |
| 2 | 91 (22.8) | 2,098 (22.8) | |
| 3 | 109 (27.3) | 2,304 (25.1) | |
| 4 | 106 (26.5) | 2,588 (28.2) | |
| Patient origin | <0.001 | ||
| Acute care hospital transfer | 13 (3.3) | 43 (0.5) | |
| Home | 364 (91.5) | 9,068 (99.0) | |
| Nursing home | 9 (2.3) | 30 (0.3) | |
| Outside emergency department transfer | 12 (3.0) | 22 (0.2) | |
| Preoperative functional status | <0.001 | ||
| Independent | 354 (88.5) | 8,974 (97.6) | |
| Partially dependent | 43 (10.8) | 170 (1.8) | |
| Fully dependent | 2 (0.5) | 7 (0.1) | |
| Body mass index | 0.03 | ||
| Underweight | 6 (1.5) | 64 (0.7) | |
| Ideal weight | 63 (15.8) | 1,182 (12.9) | |
| Overweight | 114 (28.5) | 3,077 (33.5) | |
| Obese | 217 (54.3) | 4,870 (53.0) | |
| Preoperative smoking | 0.03 | ||
| No | 330 (82.5) | 7,921 (86.2) | |
| Yes | 70 (17.5) | 1,272 (13.8) | |
| Preoperative diabetes mellitus | <0.001 | ||
| No | 248 (62.0) | 6,811 (74.1) | |
| Yes | 152 (38.0) | 2,382 (25.9) | |
| Preoperative chronic obstructive pulmonary disease | <0.001 | ||
| No | 354 (88.5) | 8,690 (94.5) | |
| Yes | 46 (11.5) | 503 (5.5) | |
| Preoperative congestive heart failure | 0.12 | ||
| No | 391 (97.8) | 9,071 (98.7) | |
| Yes | 9 (2.3) | 122 (1.3) | |
| Preoperative hypertension | 0.002 | ||
| No | 93 (23.3) | 2,797 (30.4) | |
| Yes | 307 (76.8) | 6,396 (69.6) | |
| Preoperative hemodialysis | <0.001 | ||
| No | 389 (97.3) | 9,172 (99.8) | |
| Yes | 11 (2.8) | 21 (0.2) | |
| Preoperative cancer | 0.004 | ||
| No | 396 (99.0) | 9,171 (99.8) | |
| Yes | 4 (1.0) | 22 (0.2) | |
| Preoperative immunosuppression | <0.001 | ||
| No | 356 (89.0) | 8,702 (94.7) | |
| Yes | 44 (11.0) | 491 (5.3) | |
| Preoperative bleeding disorder | 0.29 | ||
| No | 378 (94.5) | 8,503 (92.5) | |
| Yes | 21 (5.3) | 671 (7.3) | |
| Preoperative sodium | <0.001 | ||
| Hyponatremia | 44 (11.0) | 440 (4.8) | |
| Normonatremia | 350 (87.7) | 8,643 (94.3) | |
| Hypernatremia | 5 (1.3) | 80 (0.9) | |
| Preoperative platelets <100,000 | 0.04 | ||
| No | 392 (98.2) | 8,956 (99.2) | |
| Yes | 7 (1.8) | 72 (0.8) | |
| Preoperative partial thromboplastin time | <0.001 | ||
| Hypercoaguable | 17 (7.4) | 396 (7.6) | |
| Normal | 178 (77.4) | 4,466 (85.7) | |
| Hypocoaguable | 35 (15.2) | 347 (6.7) | |
| Preoperative international normalized ratio | <0.001 | ||
| Hypercoaguable | 0 (0.0) | 5 (0.1) | |
| Normal | 206 (74.1) | 5,811 (94.6) | |
| Hypocoaguable | 72 (25.9) | 328 (5.3) | |
| American Society of Anesthesiologists Score | <0.001 | ||
| 1 | 0 (0.0) | 94 (1.0) | |
| 2 | 66 (16.5) | 3,434 (37.4) | |
| 3 | 290 (72.5) | 5,401 (58.8) | |
| 4 | 44 (11.0) | 262 (2.9) | |
Values are presented as mean±standard deviation or number (%).
Table 2.
Summary of univariate comparison analyses
| Variable | Hypoalbuminemia | Normoalbuminemia | p-value |
|---|---|---|---|
| Primary outcomes | |||
| Unplanned readmission within 30-days of index surgery | <0.001 | ||
| No | 349 (87.3) | 8,737 (95.0) | |
| Yes | 51 (12.8) | 456 (5.0) | |
| Unplanned reoperation within 30-days of index surgery | 0.003 | ||
| No | 379 (94.8) | 8,941 (97.3) | |
| Yes | 21 (5.3) | 252 (2.7) | |
| Any postoperative complication | <0.001 | ||
| No | 324 (81.0) | 8,657 (94.2) | |
| Yes | 76 (19.0) | 536 (5.8) | |
| Non-home discharge | <0.001 | ||
| No | 257 (64.4) | 8,164 (88.8) | |
| Yes | 142 (35.6) | 1,026 (11.2) | |
| Mean length of stay (day) | 3.7±4.5 | 1.9±2.4 | <0.0005 |
| Secondary outcomes | |||
| Superficial surgical site infection | 0.009 | ||
| No | 390 (97.5) | 9,093 (98.9) | |
| Yes | 10 (2.5) | 100 (1.1) | |
| Deep surgical site infection | 0.15 | ||
| No | 396 (99.0) | 9,149 (99.5) | |
| Yes | 4 (1.0) | 44 (0.5) | |
| Organ space surgical site infection | 0.71 | ||
| No | 398 (99.5) | 9,158 (99.6) | |
| Yes | 2 (0.5) | 35 (0.4) | |
| Wound dehiscence | 0.02 | ||
| No | 396 (99.0) | 9,166 (99.7) | |
| Yes | 4 (1.0) | 27 (0.3) | |
| Pneumonia | <0.001 | ||
| No | 388 (97.0) | 9,144 (99.5) | |
| Yes | 12 (3.0) | 49 (0.5) | |
| Unplanned reintubation | <0.001 | ||
| No | 394 (98.5) | 9,175 (99.8) | |
| Yes | 6 (1.5) | 18 (0.2) | |
| Pulmonary embolism | 0.06 | ||
| No | 396 (99.0) | 9,158 (99.6) | |
| Yes | 4 (1.0) | 35 (0.4) | |
| Prolonged ventilator wean (>48 hr) | 0.01 | ||
| No | 398 (99.5) | 9,185 (99.9) | |
| Yes | 2 (0.5) | 8 (0.1) | |
| Renal insufficiency | 0.09 | ||
| No | 398 (99.5) | 9,197 (99.8) | |
| Yes | 2 (0.5) | 14 (0.2) | |
| Urinary tract infection | <0.001 | ||
| No | 385 (96.3) | 9,083 (98.8) | |
| Yes | 15 (3.8) | 110 (1.2) | |
| Stroke | <0.001 | ||
| No | 395 (98.8) | 9,183 (99.9) | |
| Yes | 5 (1.3) | 10 (0.1) | |
| Cardiac arrest | <0.001 | ||
| No | 395 (98.8) | 9,186 (99.9) | |
| Yes | 5 (1.3) | 7 (0.1) | |
| Myocardial infarction | <0.001 | ||
| No | 395 (98.8) | 9,170 (99.7) | |
| Yes | 5 (1.3) | 23 (0.3) | |
| Postoperative transfusion | <0.001 | ||
| No | 385 (96.3) | 9,105 (99.0) | |
| Yes | 15 (3.8) | 88 (1.0) | |
| Venous thrombosis requiring treatment | <0.001 | ||
| No | 391 (97.8) | 9,143 (99.5) | |
| Yes | 9 (2.3) | 50 (0.5) | |
| Sepsis | <0.001 | ||
| No | 390 (97.5) | 9,142 (99.4) | |
| Yes | 10 (2.5) | 51 (0.6) | |
| Septic shock | <0.001 | ||
| No | 395 (98.8) | 9,185 (99.9) | |
| Yes | 5 (1.3) | 8 (0.1) | |
| Clostridium difficile infection | <0.001 | ||
| No | 396 (99.0) | 9,183 (99.9) | |
| Yes | 4 (1.0) | 10 (0.1) | |
Values are presented as number (%) or mean±standard deviation.
Fig. 1.
Forest plot of multivariate odds of primary outcomes. Binary logistic regression performed with normoalbuminemia data as reference (i.e., hypoalbuminemia vs. normoalbuminemia). An asterisk (*) indicates statistical significance. Values are presented as odds ratio (OR) (95% confidence interval [CI]) and p-value. The overall multivariate model is statistically significant (p<0.001). 30-day readmission (OR, 1.82; 95% CI, 1.17–1.2.82; p=0.008), rates of 30-day reoperation (RTOR) (OR, 0.58; 95% CI, 0.28–1.19; p=0.13), any postoperative complication (OR, 1.08; 95% CI, 0.53–2.22; p=0.83), non-home discharge (OR, 2.08; 95% CI, 1.57–2.76; p<0.001), and length of stay (OR, 1.04; 95% CI, 1.001–1.08; p=0.04).
Fig. 2.
Forest plot of multivariate odds of primary outcomes. Binary logistic regression performed with normoalbuminemia data as reference (i.e., hypoalbuminemia vs. normoalbuminemia). An asterisk (*) indicates statistical significance. Values are presented as odds ratio (OR) (95% confidence interval [CI]) and p-value. The overall multivariate model is statistically significant (p<0.001). Clostridium difficile infection (OR, 1.77; 95% CI, 0.37–8.50; p=0.48), septic shock (OR, 2.86; 95% CI, 0.49–16.74; p=0.24), sepsis (OR, 1.64; 95% CI, 0.63–4.29; p=0.31), venous thrombosis requiring anti-coagulation (OR, 3.44; 95% CI, 1.30–9.12; p=0.01), need for blood transfusion (OR, 0.54; 95% CI, 0.23–1.27; p=0.16), myocardial infarction (OR, 1.09; 95% CI, 0.28–4.24; p=0.91), cardiac arrest (OR, 5.87; 95% CI, 0.92–37.38; p=0.06), stroke (OR, 5.12; 95% CI, 1.27–24.89; p=0.02), urinary tract infection (OR, 1.15; 95% CI, 0.48–2.77; p=0.76), renal insufficiency (OR, 0.22; 95% CI, 0.02–2.85; p=0.25), prolonged ventilator wean >48 hours (OR, 0.85; 95% CI, 0.08–9.42; p=0.89), pulmonary embolism (OR, 0.86; 95% CI, 0.23–3.24; p=0.82), unplanned re-intubation (OR, 0.78; 95% CI, 0.16–3.82; p=0.76), pneumonia (OR, 1.57; 95% CI, 0.58–4.23; p=0.38), wound dehiscence (OR, 3.09; 95% CI, 0.83–11.53; p=0.09), organ space surgical site infection (SSI) (OR, 0.34; 95% CI, 0.05–2.06; p=0.24), deep SSI (OR, 0.61; 95% CI, 0.15–2.59; p=0.51), and superficial SSI (OR, 1.28; 95% CI, 0.49–3.31; p=0.61).
Univariate analyses
Among primary outcomes, patients with preoperative hypoalbuminemia reported higher rates of 30-day readmissions (12.8% vs. 5.0%, p<0.001), RTOR (5.3% vs. 2.7%, p=0.003), postoperative complications (19.0% vs. 5.8%, p<0.001), and non-home discharge (35.6% vs. 11.2%, p<0.001) as well as longer LOS (3.7±4.5 days vs. 1.9±2.4 days, p<0.001) compared with those having normoalbuminemia. Among secondary outcomes, patients with hypoalbuminemia reported higher rates of infectious complications (superficial surgical site infection: 2.5% vs. 1.1%, p=0.009; pneumonia: 3.0% vs. 0.5%, p<0.001; urinary tract infection: 3.8% vs. 1.2%, p<0.001; sepsis: 2.5% vs. 0.6%, p<0.001; septic shock: 1.3% vs. 0.1%, p<0.001; Clostridium difficile infection: 1.0% vs. 0.1%, p<0.001), wound dehiscence (1.0% vs. 0.3%, p=0.02), pulmonary complications (unplanned reintubation: 1.5% vs. 0.2%, p<0.001; prolonged ventilator wean >48 hours: 0.5% vs. 0.1%, p=0.01), and cardiovascular complications (stroke: 1.3% vs. 0.1%, p<0.001; myocardial infarction: 1.3% vs. 0.3%, p<0.001; venous thrombosis requiring anticoagulation: 2.3% vs. 0.5%, p<0.001) (Table 2).
Multivariate analysis
The assessment of the association of primary outcomes to albumin status revealed that those with hypoalbuminemia reported higher rates of 30-day readmission (OR, 1.82; 95% CI, 1.17–1.2.82; p=0.008), non-home discharge (OR, 2.08; 95% CI, 1.57–2.76; p<0.001), and longer LOS (OR, 1.04; 95% CI, 1.001–1.08; p=0.04). However, the odds of RTOR (OR, 0.58; 95% CI, 0.28–1.19; p=0.13) and postoperative complications (OR, 1.08; 95% CI, 0.53–2.22; p=0.83) were similar. Among secondary outcomes, the odds of venous thrombosis requiring anticoagulation (OR, 3.44; 95% CI, 1.30–9.12; p=0.01) and stroke (OR, 5.12; 95% CI, 1.27–24.89; p=0.02) were higher among those with hypoalbuminemia. The odds of the remaining secondary outcomes occurring did not differ (Fig. 2).
Discussion
Lumbar stenosis is among the most prevalent degenerative spine pathologies, with an estimated prevalence of 11%–39% in the general population [21]. Approximately 600,000 decompressive surgeries are performed annually in the United States alone for lumbar spinal stenosis [2]. Many of those procedures are considered elective and are performed on an outpatient basis. Despite its routine use, surgical outcomes after lumbar laminectomy are affected by patient-level factors, including comorbidities and nutritional status. Significant amounts of prior literature have investigated the impact of malnutrition on outcomes in spinal fusion and spine oncology surgery; however, no previous literature has examined the effect of malnutrition on outcomes after elective lumbar laminectomies without fusion. Our analysis reveals that hypoalbuminemia in adult patients undergoing elective open lumbar laminectomies for lumbar stenosis is associated with greater rates of 30-day readmission, non-home discharge, and longer LOS, in addition to increased postoperative complications, including wound complications, pulmonary complications, venous thrombosis requiring anticoagulation, and stroke.
Malnutrition has affected several aspects of surgical care and is a significant predictor of poor surgical outcomes [5,7,22,23]. Nipper et al. [22] previously revealed that preoperative hypoalbuminemia is associated with increased risk of mortality and prolonged LOS across various surgical specialties, including general surgery, cardiac surgery, neurosurgery, orthopedic surgery, vascular surgery, and gynecology. The pathophysiologic basis for this association is well established: malnutrition impairs immune function, delays wound healing, and heightens susceptibility to perioperative infections [24,25]. Considering these risks, optimizing nutritional status preoperatively has appeared as a key strategy for improving surgical outcomes. Current guidelines recommend caloric goals of 25 kcal/kg/day and protein intake of 1–2 g/kg/day to mitigate the effect of malnutrition, promote tissue healing, and improve immune function [26,27]. Therefore, early identification of patients with malnutrition and implementation of targeted nutritional interventions may play a crucial role in reducing postoperative complications, particularly in elective surgical populations where prehabilitation is feasible.
Postoperative nutritional interventions still provide an important opportunity to improve outcomes when preoperative optimization is not possible. Previous literature has demonstrated that postoperative nutritional supplementation in patients with malnutrition is associated with reduced LOS, improved quality of life, and lower surgical morbidity [28,29]. This is achieved via oral, enteral, or, in severe cases, parenteral nutritional support. Despite this evidence, perioperative nutritional supplementation remains underutilized. Williams et al. recently revealed that among a cohort of 2.8 million patients undergoing surgery, only 15% of individuals with malnutrition received perioperative nutritional support [30]. The underuse may indicate a combination of factors, including lack of standardized perioperative nutrition protocols and under-recognition of malnutrition. Given our results and the broader literature, spine surgeons should consider integrating perioperative nutritional strategies into routine clinical care to improve recovery and minimize complication risks, even in shorter, more routine spinal decompressions without fusion.
Previous research has established the effect of malnutrition in more invasive spinal surgeries; however, our study extends these findings to shorter, less tissue-disruptive elective lumbar decompressions. Previously, Elsamadicy et al. [5] revealed that among patients undergoing posterior lumbar decompression and fusion, malnutrition was associated with longer LOS, increased adverse events, reoperations, and readmissions. Similarly, malnutrition was associated with higher rates of mortality, non-home discharge, and reoperation in spinal epidural abscess surgery [6]. These findings may seem rather obvious, considering the known effect of malnutrition on immune functioning and tissue/wound healing, whereas our study uniquely indicates that malnutrition significantly impacts outcomes even after less invasive elective surgeries such as lumbar laminectomy without fusion due to lumbar stenosis. These results indicate that nutritional status should be considered across the full spectrum of spinal operations, not only for major reconstructive surgeries or when performed due to underlying infection.
However, the decision to proceed with elective lumbar laminectomy for the treatment of lumbar stenosis should be individualized to the patient’s needs. Our results clearly extend the findings of previous literature on malnutrition in spine surgery to elective lumbar laminectomies; however, it may not always be possible or optimize preoperative nutrition. The benefits of timely surgery may outweigh the risks associated with preoperative hypoalbuminemia in cases where neurologic deficits, severe pain, or functional decline are prominent. In such scenarios, postoperative nutritional support remains a crucial adjunct to mitigate risks. Our study, revealing increased odds of thromboembolic events, likely represents poor patient mobilization, a well-known risk factor for thrombotic events, during malnutrition. Limited mobility is further reflected by increased odds of non-home discharge (i.e., need for rehab) as well as heightened wound complication rates likely due to pressure on the wound, whereas recumbent and pulmonary complications are caused by resultant atelectasis and subsequent complications, including pneumonia. Recognizing the association between hypoalbuminemia and worse short-term outcomes—including higher readmission, non-home discharge, and postoperative complication rates—surgeons should develop strategies to improve nutritional status wherever feasible while not unduly delaying necessary surgical care.
The present study has several limitations that should be addressed. First, the retrospective design, although necessary when employing national databases, such as NSQIP, limits causal interpretations. The NSQIP database only obtains 30-day outcomes postoperatively and does not include longer-term follow-up or patient-reported outcomes, which may miss important sequelae. Further, NSQIP data lack granular information regarding perioperative nutritional interventions, social determinants of health, and institutional care pathways—all of which could affect outcomes. Reasons for 30-day readmission and RTOR are frequently missing, which limits the ability to further understand where improvement in perioperative care can be made. Limited data were available regarding the number of levels that underwent decompression; thus, this variable could not be controlled for. However, even multilevel lumbar decompressions typically have less tissue dissection and operative times compared with fusions. Nutritional studies within spine literature almost exclusively include fusion surgeries; thus, these data remain important despite limited ability to control for levels. Furthermore, differences between institutional postoperative care certainly exist, causing an inherently heterogeneous postoperative experience within NSQIP data. Lastly, variability in surgical practices and postoperative management across institutions introduces unavoidable heterogeneity into the dataset.
Conclusions
Preoperative hypoalbuminemia is associated with higher rates of 30-day readmission, non-home discharge, postoperative complications, and longer LOS among adults undergoing elective open lumbar laminectomy for lumbar stenosis. These results underscore the importance of preoperative nutritional optimization, even in shorter and more routine spinal surgery.
Key Points.
Malnutrition is associated with more 30-day readmissions, non-home discharges, and postoperative complications.
Malnutrition is associated with a longer length of stay.
Perioperative nutritional assessment is crucial even in shorter, routine spinal surgery.
Footnotes
Conflict of Interest
No potential conflict of interest relevant to this article was reported.
Acknowledgments
American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
Author Contributions
Conceptualization: TF, PR. Methodology: TF, PR. Validation: TF, PR, AS, TS. Formal analysis: TF. Writing–original draft: TF, PR, AS. Writing–review and editing: TF, PR, AS, TS. Supervision: TF, TS. Final approval of the manuscript: all authors.
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