Risk Factors Affecting Spinal Fusion: A Meta-analysis of 39 Cohort Studies

Overview

Journal PLoS One

Specialties General Medicine
Science

Date 2024 Jun 7

PMID 38848350

Authors

Shudong Yang

Beijun Zhou

Jiaxuan Mo

Ruidi He

Kunbo Mei

Zhi Zeng

Gaigai Yang

Yuwei Chen

Mingjiang Luo

Siliang Tang

Zhihong Xiao

Affiliations

Soon will be listed here.

Abstract

Purpose: We performed a meta-analysis to identify risk factors affecting spinal fusion.

Methods: We systematically searched PubMed, Embase, and the Cochrane Library from inception to January 6, 2023, for articles that report risk factors affecting spinal fusion. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using fixed-effects models for each factor for which the interstudy heterogeneity I2 was < 50%, while random-effects models were used when the interstudy heterogeneity I2 was ≥ 50%. Using sample size, Egger's P value, and heterogeneity across studies as criteria, we categorized the quality of evidence from observational studies as high-quality (Class I), moderate-quality (Class II or III), or low-quality (Class IV). Furthermore, the trim-and-fill procedure and leave-one-out protocol were conducted to investigate potential sources of heterogeneity and verify result stability.

Results: Of the 1,257 citations screened, 39 unique cohort studies comprising 7,145 patients were included in the data synthesis. High-quality (Class I) evidence showed that patients with a smoking habit (OR, 1.57; 95% CI, 1.11 to 2.21) and without the use of bone morphogenetic protein-2 (BMP-2) (OR, 4.42; 95% CI, 3.33 to 5.86) were at higher risk for fusion failure. Moderate-quality (Class II or III) evidence showed that fusion failure was significantly associated with vitamin D deficiency (OR, 2.46; 95% CI, 1.24 to 4.90), diabetes (OR, 3.42; 95% CI, 1.59 to 7.36), allograft (OR, 1.82; 95% CI, 1.11 to 2.96), conventional pedicle screw (CPS) fixation (OR, 4.77; 95% CI, 2.23 to 10.20) and posterolateral fusion (OR, 3.63; 95% CI, 1.25 to 10.49).

Conclusions: Conspicuous risk factors affecting spinal fusion include three patient-related risk factors (smoking, vitamin D deficiency, and diabetes) and four surgery-related risk factors (without the use of BMP-2, allograft, CPS fixation, and posterolateral fusion). These findings may help clinicians strengthen awareness for early intervention in patients at high risk of developing fusion failure.

References

Wang H, Meng Y, Liu H, Wang X, Hong Y . The impact of smoking on outcomes following anterior cervical fusion-nonfusion hybrid surgery: a retrospective single-center cohort study. BMC Musculoskelet Disord. 2021; 22(1):612. PMC: 8272305. DOI: 10.1186/s12891-021-04501-4. View

Mundis G, Eastlack R, Moazzaz P, Turner A, Cornwall G . Contribution of Round vs. Rectangular Expandable Cage Endcaps to Spinal Stability in a Cadaveric Corpectomy Model. Int J Spine Surg. 2015; 9:53. PMC: 4657610. DOI: 10.14444/2053. View

Niu S, Anastasio A, Faraj R, Rhee J . Evaluation of Heterotopic Ossification After Using Recombinant Human Bone Morphogenetic Protein-2 in Transforaminal Lumbar Interbody Fusion: A Computed Tomography Review of 996 Disc Levels. Global Spine J. 2020; 10(3):280-285. PMC: 7160810. DOI: 10.1177/2192568219846074. View

Tavares W, Araujo de Franca S, Paiva W, Teixeira M . A systematic review and meta-analysis of fusion rate enhancements and bone graft options for spine surgery. Sci Rep. 2022; 12(1):7546. PMC: 9085837. DOI: 10.1038/s41598-022-11551-8. View

Peters J, Sutton A, Jones D, Abrams K, Rushton L . Comparison of two methods to detect publication bias in meta-analysis. JAMA. 2006; 295(6):676-80. DOI: 10.1001/jama.295.6.676. View

Daftari T, Whitesides Jr T, Heller J, Goodrich A, McCarey B, Hutton W . Nicotine on the revascularization of bone graft. An experimental study in rabbits. Spine (Phila Pa 1976). 1994; 19(8):904-11. DOI: 10.1097/00007632-199404150-00007. View

Tuli S, Tuli J, Chen P, Woodard E . Fusion rate: a time-to-event phenomenon. J Neurosurg Spine. 2004; 1(1):47-51. DOI: 10.3171/spi.2004.1.1.0047. View

Glassman S, Alegre G, Carreon L, Dimar J, Johnson J . Perioperative complications of lumbar instrumentation and fusion in patients with diabetes mellitus. Spine J. 2003; 3(6):496-501. DOI: 10.1016/s1529-9430(03)00426-1. View

Wukich D . Diabetes and its negative impact on outcomes in orthopaedic surgery. World J Orthop. 2015; 6(3):331-9. PMC: 4390895. DOI: 10.5312/wjo.v6.i3.331. View

10.

Cammisa Jr F, Lowery G, Garfin S, Geisler F, Klara P, McGuire R . Two-year fusion rate equivalency between Grafton DBM gel and autograft in posterolateral spine fusion: a prospective controlled trial employing a side-by-side comparison in the same patient. Spine (Phila Pa 1976). 2004; 29(6):660-6. DOI: 10.1097/01.brs.0000116588.17129.b9. View

11.

Deyo R, Gray D, Kreuter W, Mirza S, Martin B . United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976). 2005; 30(12):1441-5. DOI: 10.1097/01.brs.0000166503.37969.8a. View

12.

Luo M, Cao Q, Wang D, Tan R, Shi Y, Chen J . The impact of diabetes on postoperative outcomes following spine surgery: A meta-analysis of 40 cohort studies with 2.9 million participants. Int J Surg. 2022; 104:106789. DOI: 10.1016/j.ijsu.2022.106789. View

13.

Zhang W, Li L, Zhou X, Li K, Liu C, Lin X . Concurrent Treatment with Vitamin K2 and D3 on Spine Fusion in Patients with Osteoporosis-Associated Lumbar Degenerative Disorders. Spine (Phila Pa 1976). 2021; 47(4):352-360. DOI: 10.1097/BRS.0000000000004309. View

14.

Stang A . Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010; 25(9):603-5. DOI: 10.1007/s10654-010-9491-z. View

15.

Wu Z, Gong F, Liu L, Ma Z, Zhang Y, Zhao X . A comparative study on screw loosening in osteoporotic lumbar spine fusion between expandable and conventional pedicle screws. Arch Orthop Trauma Surg. 2011; 132(4):471-6. DOI: 10.1007/s00402-011-1439-6. View

16.

Oliveira O, Martins S, Lima W, Gomes M . The use of bone morphogenetic proteins (BMP) and pseudarthrosis, a literature review. Rev Bras Ortop. 2017; 52(2):124-140. PMC: 5380784. DOI: 10.1016/j.rboe.2016.03.005. View

17.

Samartzis D, Shen F, Matthews D, Yoon S, Goldberg E, An H . Comparison of allograft to autograft in multilevel anterior cervical discectomy and fusion with rigid plate fixation. Spine J. 2003; 3(6):451-9. DOI: 10.1016/s1529-9430(03)00173-6. View

18.

Mei J, Song X, Guan X, Wu D, Wang J, Liu Q . Postoperative bisphosphonate do not significantly alter the fusion rate after lumbar spinal fusion: a meta-analysis. J Orthop Surg Res. 2021; 16(1):284. PMC: 8082634. DOI: 10.1186/s13018-021-02444-z. View

19.

Ravindra V, Guan J, Holland C, Dailey A, Schmidt M, Godzik J . Vitamin D status in cervical spondylotic myelopathy: comparison of fusion rates and patient outcome measures. J Neurosurg Sci. 2016; 63(1):36-41. DOI: 10.23736/S0390-5616.16.03846-7. View

20.

Mei Z, Wang Q, Zhang Y, Liu P, Ge M, Du P . Risk Factors for Recurrence after anal fistula surgery: A meta-analysis. Int J Surg. 2019; 69:153-164. DOI: 10.1016/j.ijsu.2019.08.003. View