Optimal hemoglobin A1C target in diabetics undergoing elective cervical spine surgery |
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| Institution: | 1. Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA;2. Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA;3. Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA;4. Department of Orthopaedic Surgery, Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA;5. Department of Physical Medicine and Rehabilitation, Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN, USA;6. Department of Orthopedic Surgery, Steamboat Orthopedics and Spine Institute, Steamboat Springs, CO, USA;1. Geisel School of Medicine at Dartmouth, 1 Rope Ferry Road Hanover, NH 03755, USA;2. Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA;1. Department of Orthopaedic Surgery, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan;2. Department of Orthopaedic Surgery, National Hospital Organization, Sagamihara Hospital, 18-1 Sakuradai, Minami-ku, Sagamihara, Kanagawa, Japan;1. Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, Palo Alto, CA 94305, USA;2. Department of Physical Medicine and Rehabilitation, Kaiser Permanente San Rafael Medical Center, San Rafael, CA 94903, USA;3. Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA;4. Department of Medicine, Division of Community Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA;5. Department of Radiology, Mayo Clinic, Rochester, MN, 55905, USA;1. Department of Neurosurgery, Center for Spine Health, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA;2. Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH, USA;3. Center for Outcomes Research and Evaluation, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH, USA;4. Center for Medical Art and Photography, Cleveland Clinic Foundation, Cleveland, OH, USA;5. Department of Neurosurgery, Hospitals of the University of Pennsylvania, Philadelphia, PA, USA;6. Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Education Institute, Cleveland Clinic, Cleveland, OH, USA;1. Department of Medicine, Division of Community Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA;2. Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University, Palo Alto, CA 94305, USA;3. Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA;4. Department of Physical Medicine and Rehabilitation, Kaiser Permanente San Rafael Medical Center, San Rafael, CA 94903, USA;5. Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA;6. Department of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA;1. Department of Orthopedics, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands;2. Department of Orthopaedic Surgery, Keio University School of Medicine, 35, Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan;3. Department of Orthopaedic Surgery, National Defense Medical College, 3-2, Namniki, Tokorozawa, Saitama, 359-8513, Japan;4. Department of Research, Sint Maartenskliniek, P.O. Box 9011, 6500 GM Nijmegen, The Netherlands;5. The Health Scientist, 2532 TX, The Hague, The Netherlands |
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| Abstract: | BACKGROUND CONTEXTDiabetes mellitus (DM) is a well-established risk factor for suboptimal outcomes following cervical spine surgery. Hemoglobin A1C (HbA1c), a surrogate for long-term glycemic control, is a valuable assessment tool in diabetic patients.PURPOSEIn patients undergoing elective cervical spine surgery, we sought to identify optimal HbA1c levels to: (1) maximize 1-year postoperative patient-reported outcomes (PROs), and (2) predict the occurrence of medical and surgical complications.STUDY DESIGN/SETTINGA retrospective cohort study using prospectively collected data was performed in a single academic center.Patient SampleDiabetic patients undergoing elective anterior cervical fusion and posterior cervical laminectomy and fusion (PCLF) between October 2010-March 2021 were included.OUTCOME MEASURESPrimary outcomes included Numeric Rating Scale (NRS)-Neck pain, NRS-Arm pain, and Neck Disability Index (NDI). Secondary outcomes included surgical site infection (SSI), complications, readmissions, and reoperations within 90-days postoperatively.METHODSHbA1c, demographic, comorbidity, and perioperative variables were gathered in diabetic patients only. PROs were analyzed as continuous variables and minimum clinically difference (MCID) was set at 30% improvement from baseline.RESULTSOf 1992 registry patients undergoing cervical surgery, 408 diabetic patients underwent cervical fusion surgery. Anterior: A total of 259 diabetic patients underwent anterior cervical fusion, 141 of which had an available HbA1c level within one year prior to surgery. Mean age was 55.8±10.1, and mean HbA1c value was 7.2±1.4. HbA1c levels above 6.1 were associated with failure to achieve MCID for NDI (AUC=0.77, 95%CI 0.70–0.84, p<.001), and HbA1c levels above 6.8 may be associated with increased odds of reoperation (AUC=0.61, 95%CI 0.52–0.69, p=.078). Posterior: A total of 149 diabetic patients underwent PCLF, 65 of which had an available HbA1c level within 1 year. Mean age was 63.6±9.2, and mean HbA1c value was 7.2±1.5. Despite a low AUC for NRS-Arm pain and readmission, HbA1c levels above 6.8 may be associated with failure to achieve MCID for NRS-Arm pain (AUC=0.61, 95%CI 0.49–0.73, p=.094), and HbA1c levels above 7.6 may be associated with higher readmission rate (AUC=0.63, 95%CI 0.50–0.75, p=.185).CONCLUSIONSIn a cohort of diabetic patients undergoing elective cervical spine surgery, HbA1c levels above 6.1 were associated with decreased odds of achieving MCID for NDI in anterior cervical fusion surgery. Though only moderate associations were seen for the select outcomes of reoperation (6.8), readmission (7.6), and MCID for NRS-Arm pain (6.8), preoperative optimization of HbA1c using these levels as benchmarks should be considered to reduce the risk of complications and maximize PROs for patients undergoing elective cervical spine surgery. |
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