Redefining Clinically Significant Blood Loss in Complex Adult Spine Deformity Surgery

Mohammad Daher; Andrew Xu; Manjot Singh; Renaud Lafage; Breton G Line; Lawrence G Lenke; Christopher P Ames; Douglas C Burton; Stephen M Lewis; Robert K Eastlack; Munish C Gupta; Gregory M Mundis; Jeffrey L Gum; Kojo D Hamilton; Richard Hostin; Virginie Lafage; Peter G Passias; Themistocles S Protopsaltis; Khaled M Kebaish; Frank J Schwab; Christopher I Shaffrey; Justin S Smith; Shay Bess; Eric O Klineberg; Bassel G Diebo; Alan H Daniels; International Spine Study Group (ISSG)

doi:10.1097/BRS.0000000000005250

Redefining Clinically Significant Blood Loss in Complex Adult Spine Deformity Surgery

Spine (Phila Pa 1976). 2024 Dec 25. doi: 10.1097/BRS.0000000000005250. Online ahead of print.

Authors

Mohammad Daher¹, Andrew Xu¹, Manjot Singh¹, Renaud Lafage², Breton G Line³, Lawrence G Lenke⁴, Christopher P Ames⁵, Douglas C Burton⁶, Stephen M Lewis⁷, Robert K Eastlack⁸, Munish C Gupta⁹, Gregory M Mundis⁸, Jeffrey L Gum¹⁰, Kojo D Hamilton¹¹, Richard Hostin¹², Virginie Lafage², Peter G Passias¹³, Themistocles S Protopsaltis¹³, Khaled M Kebaish¹⁴, Frank J Schwab², Christopher I Shaffrey¹⁵, Justin S Smith¹⁶, Shay Bess³, Eric O Klineberg¹⁷, Bassel G Diebo¹, Alan H Daniels¹; International Spine Study Group (ISSG)

Affiliations

¹ Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
² Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA.
³ Department of Spine Surgery, Denver International Spine Center, Denver, Colorado, USA.
⁴ Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York, USA.
⁵ Department of Neurological Surgery, University of California, San Francisco, California, USA.
⁶ Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA.
⁷ Department of Orthopedics, University of Toronto, Toronto, Canada.
⁸ Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA.
⁹ Department of Orthopedic Surgery, Washington University, St. Louis, Missouri, USA.
¹⁰ Norton Leatherman Spine Center, Louisville, Kentucky, USA.
¹¹ Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
¹² Southwest Scoliosis and Spine Institute, Plano, Texas, USA.
¹³ Department of Orthopedics, New York University Langone Orthopedic Hospital, New York, New York, USA.
¹⁴ Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
¹⁵ Department of Neurosurgery, Duke Spine Division, Durham, North Carolina, USA.
¹⁶ Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia, USA.
¹⁷ Department of Orthopedic Surgery, University of Texas McGovern Medical School, Houston, Texas, USA.

PMID: 39722533
DOI: 10.1097/BRS.0000000000005250

Abstract

Study design: Retrospective analysis of prospectively-collected data.

Objective: This study aims to define clinically relevant blood loss in adult spinal deformity (ASD) surgery.

Background: Current definitions of excessive blood loss following spine surgery are highly variable and may be suboptimal in predicting adverse events (AE).

Methods: Adults undergoing complex ASD surgery were included. Estimated blood loss (EBL) was extracted for investigation, and estimated blood volume loss (EBVL) was calculated by dividing EBL by the preoperative blood volume utilizing Nadler's formula. LASSO regression was performed to identify five variables from demographic and peri-operative parameters. Logistic regression was subsequently performed to generate a receiver operating characteristics (ROC) curve and estimate an optimal threshold for EBL and EBVL. Finally, the proportion of patients with AE plotted against EBL and EBVL to confirm the identified thresholds.

Results: In total 552 patients were included with a mean age of 60.7±15.1 years, 68% females, mean CCI was 1.0±1.6, and 22% experienced AEs. LASSO regression identified ASA score, baseline hypertension, preoperative albumin, and use of intra-operative crystalloids as the top predictors of an AE, in addition to EBL/EBVL. Logistic regression resulted in ROC curve which was used to identify a cut-off of 2.3 liters of EBL and 42% for EBVL. Patients exceeding these thresholds had AE rates of 36% (odds-ratio: 2.1, 95% CI [1.2-3.6]) and 31% (odds-ratio: 1.7, 95% CI [1.1-2.8]), compared to 21% for those below the thresholds of EBL and EBVL, respectively.

Conclusion: In complex ASD surgery, intraoperative EBL of 2.3 liters and an EBVL of 42% are associated with clinically-significant AEs. These thresholds may be useful in guiding preoperative-patient-counseling, healthcare system quality initiatives, and clinical perioperative bloodloss management strategies in patients undergoing complex spine surgery. Additionally, similar methodology could be performed in other specialties to establish procedure-specific clinically-relevant bloodloss thresholds.