SPINE Volume 40, Number 19, pp 1527-1535

©2015, Wolters Kluwer Health, Inc. All rights reserved.

EPIDEMIOLOGY

Timing of Complications After Spinal Fusion

Surgery
Daniel D. Bohl, MD, MPH,* Matthew L. Webb, AB,† Adam M. Lukasiewicz, MSc,† Andre M. Samuel, BBA,†
Bryce A. Basques, MD,* Junyoung Ahn, BS,* Kern Singh, MD,* Alexander R. Vaccaro, MD,‡ and
Jonathan N. Grauer, MD†

Conclusion. These precisely described postoperative time periods

Study Design. Retrospective cohort study.
enable heightened clinical awareness among spine surgeons.
Objective. To characterize the timing of complications after spinal
Spine surgeons should have the lowest threshold for testing for
fusion procedures.
each complication during the time period of greatest risk. Authors,
Summary of Background Data. Despite many publications
reviewers, and surgeons utilizing research on postoperative
on risk factors for complications after spine surgery, there are few
complications should carefully consider the impact that the duration
publications on the timing at which such complications occur.
of follow-up has on study results.
Methods. Patients undergoing anterior cervical decompression
Key words: postoperative complications, timing, anterior cervical
and fusion (ACDF) or posterior lumbar fusion (PLF; with or
decompression and fusion, posterior lumbar fusion, anemia
without interbody) procedures during 2011–2013 were identified
requiring transfusion, myocardial infarction, pneumonia, pulmonary
in the American College of Surgeons National Surgical Quality
embolism, deep vein thrombosis, sepsis, surgical site infection,
Improvement Program (ACS-NSQIP) database. For each of 8 different
urinary tract infection.
complications, the median time from surgery until complication was
Level of Evidence: 3
determined, along with the interquartile range and middle 80%.
Spine 2015;40:1527–1535
Results. A total of 12,067 patients undergoing ACDF and 11,807
patients undergoing PLF were identified. For ACDF, the median
day of diagnosis (and interquartile range; middle 80%) for anemia
requiring transfusion was 0 (0–1; 0–2), myocardial infarction 2 (1–

5; 0–15), pneumonia 4 (2–9; 1–14), pulmonary embolism 5 (2–9;
1–10), deep vein thrombosis 10.5 (7–16.5; 5–21), sepsis 10.5 (4–
18; 1–23), surgical site infection 13 (8–19; 5–25), and urinary tract
infection 17 (8–22; 4–26). For PLF, the median day of diagnosis (and
interquartile range; middle 80%) for anemia requiring transfusion
was 0 (0–1; 0–2), myocardial infarction 2 (1–4; 1–8), pneumonia
4 (2–9; 1–17), pulmonary embolism 5 (3–11; 2–17), urinary tract
infection 7 (4–14; 2–23), deep vein thrombosis 8 (5–16; 3–20),
sepsis 9 (4–16; 2–22), and surgical site infection 17 (13–22; 9–27).
From the *Department of Orthopaedic Surgery, Rush University Medical
Center, Chicago, IL; †Department of Orthopaedics and Rehabilitation, Yale
School of Medicine, New Haven, CT; and ‡Departments of Orthopaedic
Surgery and Neurological Surgery, Thomas Jefferson University and The
Rothman Institute, Philadelphia, PA.
Acknowledgment date: December 29, 2014. Revision date: April 26, 2015.
Acceptance date: May 11, 2015.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work.
Relevant financial activities outside the submitted work: board membership,
consultancy, employment, expert testimony, grants, royalties, stocks.
Address correspondence and reprint requests to: Jonathan N. Grauer, MD,
Department of Orthopaedics and Rehabilitation, Yale School of Medicine,
800 Howard Ave, New Haven, CT 06510; E-mail: jonathan.grauer@yale.edu
DOI: 10.1097/BRS.0000000000001073
Spine
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S
pine surgeons often rely on conventional wisdom to
describe the delay between surgery and the occurrence
of postoperative complications. Some of this informa-
tion stems from teachings during medical school and resi-
dency.1 For example, one popular medical school teaching is
“wind (pneumonia [days 1–3]), water (urinary tract infection
[days 3–5]), walk (venous thromboembolism [days 4–7]), and
wound (surgical site infection [days 5–10]).”1 However, this
information may not be evidence-based and oftentimes stems
from teachings in the field of general surgery.
Many recent publications have characterized risk factors
for complications after spine surgery.2–16 However, few publi-
cations have characterized the timing of these complications.
Information on the timing of complications may help to opti-
mize early detection and treatment.
The absence of publication on the timing of complications
may be partially due to the small sample sizes of many single-
and multicenter studies. In addition, although nationwide
databases have become popular for use in research due to
their large sample sizes,2,17 most nationwide databases do not
capture the timing of postoperative complications.
The present study characterizes the timing of 8 compli-
cations after 2 common types of spinal fusion surgery uti-
lizing the American College of Surgeons National Surgical
Quality Improvement Program (ACS-NSQIP). This surgical
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 EPIDEMIOLOGY Timing of Complications • Bohl et al

registry is well suited to study the timing of complications Figures 1 and 2 provide histograms and hazard curves
due to its adherence to specific complication definitions depicting the timing of complications. The figures are ordered
and 30-day follow-up. The study’s results should assist sur- by increasing median time until diagnosis.
geons in optimizing postoperative management. As a sec- Figure 3 depicts medians, interquartile ranges, and middle
ondary aim, the study will explore the covariance between 80% ranges for the timing of each complication. For ACDF,
complications. the median day of diagnosis (and interquartile range; middle
80%) for anemia requiring transfusion was 0 (0–1; 0–2), MI
MATERIALS AND METHODS 2 (1–5; 0–15), pneumonia 4 (2–9; 1–14), PE 5 (2–9; 1–10),
A retrospective cohort study was conducted. The 2011–2013 DVT 10.5 (7–16.5; 5–21), sepsis 10.5 (4–18; 1–23), SSI 13
ACS-NSQIP database was accessed.18 From this database, (8–19; 5–25), and UTI 17 (8–22; 4–26). For PLF, the median
procedures were included that utilized current procedural day of diagnosis (and interquartile range; middle 80%) for
terminology codes for either anterior cervical decompression
and fusion (ACDF; 22551 or 22554) or posterior lumbar
fusion (PLF; with or without interbody; 22,612, 22,630, or
22,633) procedures. An additional inclusion criterion was the
characterization of the procedure as elective. TABLE 1. Patients Undergoing Anterior Cervical
The ACS-NSQIP identifies patients undergoing surgical Decompression and Fusion Procedures
procedures at participating community and academic cen-
Number Percent
ters.2,17,18 Baseline demographic and comorbidity characteris-
tics are documented. Patients are followed for the develop- Total 12,067 100.0
ment of complications for 30 postoperative days, including Age
after discharge. When complications occur, the postoperative
day of diagnosis is recorded.18 Of note, blood transfusion is ≤49 4534 37.6
only recorded during the first 3 postoperative days. 50–59 4034 33.4
For the present study, demographic and comorbidity data 60–69 2403 19.9
were tabulated. The timing of 8 postoperative complications
was characterized. These complications included anemia ≥70 1096 9.1
requiring transfusion, myocardial infarction (MI), pneumo- Sex
nia, pulmonary embolism (PE), deep vein thrombosis (DVT),
Male 5769 47.8
sepsis (which included sepsis both with and without shock),
surgical site infection (SSI; which included both superficial Female 6298 52.2
and deep surgical site infection), and urinary tract infection Body mass index
(UTI). Full descriptions of the specific definitions of these
≤24 2632 21.8
complications can be found in the ACS-NSQIP materials.18
For each of these complications, the followings were deter- 25–29 4146 34.4
mined: (1) the rate of occurrence during the 30 days after sur- 30–34 3008 24.9
gery, (2) the median, interquartile range, and middle 80% for
days after surgery on which diagnosis occurred, and (3) the ≥35 2281 18.9
proportion of diagnoses before (vs. after) discharge. The first Functional status
2 of these analyses were stratified by the number of operative
Independent 11,898 98.6
levels (for both ACDF and PLF) and the use of an interbody
device (for PLF). Rates of occurrence during the 30 days after Dependent 169 1.4
surgery were compared using Pearson’s χ2 test. Finally, a cova- Diabetes 1716 14.2
riance matrix was created to examine the correlation of the 8
Congestive heart failure 16 0.1
complications with each other. The level of significance as set
to 0.05. Dyspnea on exertion 709 5.9
Hypertension 5177 42.9
RESULTS
End-stage renal disease 27 0.2
A total of 12,067 patients undergoing ACDF and 11,807
patients undergoing PLF met inclusion criteria. Tables 1 and 2 COPD 480 4.0
summarize the demographic and comorbidity characteristics Number of levels
of the included patients. Tables 3 and 4 provide the rates at
1 6914 57.3
which complications were diagnosed. These results are strati-
fied by number of operative levels (for ACDF and PLF) and 2 4514 37.4
use of an interbody device (for PLF) in the Supplemental Digi- ≥3 639 5.3
tal Content Appendices 1–3, available at: http://links.lww.
COPD indicates chronic obstructive pulmonary disease.
com/BRS/B19.
1528 www.spinejournal.com October 2015
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 EPIDEMIOLOGY Timing of Complications • Bohl et al

TABLE 2. Patients Undergoing Posterior Lumbar TABLE 3. Number and Percent of Patients
Fusion Procedures Who Developed Complications
Number Percent During the 30 days After Anterior
Total 11,807 100.0
Cervical Decompression and Fusion
Procedures (N = 12,067)
Age
No.
≤49 2510 21.3 Complication Patients Percent 95% CI
50–59 2809 23.8 Anemia requiring transfusion 64 0.53 0.40–0.66
60–69 3255 27.6 Pneumonia 58 0.48 0.36–0.60
≥70 3233 27.4 Surgical site infection 49 0.41 0.29–0.52
Sex Urinary tract infection 43 0.36 0.25–0.46
Male 5251 44.5 Sepsis 28 0.23 0.15–0.32
Female 6556 55.5 Deep vein thrombosis 24 0.20 0.12–0.28
Body mass index Myocardial infarction 16 0.13 0.07–0.20
≤24 2244 19.0 Pulmonary embolism 13 0.11 0.05–0.17
25–29 3964 33.6 CI indicates confidence interval.

30–34 3100 26.3

≥35 2499 21.2
Figure 4 provides the proportions of complications that
were diagnosed before (vs. after) discharge.
Functional status Tables 5 and 6 are covariance matrices for occurrence of
Independent 11,526 97.6 the 8 complications after ACDF (Table 5) and PLF (Table 6).
The tables provide correlation coefficients and P-values for
Dependent 281 2.4
each of the potential 2-way comparisons. Of the 254 patients
Diabetes 1929 16.3 who had complications after ACDF, 34 (13.4%) had multiple
Congestive heart failure 30 0.3 complications. Similarly, of the 2,497 patients who had com-
plications after PLF, 277 (11.1%) had multiple complications.
Dyspnea on exertion 872 7.4
Hypertension 6665 56.5 DISCUSSION
End-stage renal disease 17 0.1 The present study examines more than 20,000 spinal fusion
procedures from a surgical registry to characterize the timing
COPD 529 4.5
Current smoker 2558 21.7
Number of levels
TABLE 4. Number and Percent of Patients Who
1 6861 58.1 Developed Complications During the
2 3906 33.1 30 days After Posterior Lumbar Fusion
≥3 1040 8.8 Procedures (N = 11,807)
Interbody No.
Complication Patients Percent 95% CI
No 6713 56.9
Anemia requiring transfusion 2060 17.45 16.76–18.13
Yes 5094 43.1
Urinary tract infection 208 1.76 1.52–2.00
COPD indicates chronic obstructive pulmonary disease.
Surgical site infection 208 1.76 1.52–2.00
Sepsis 101 0.86 0.69–1.02
anemia requiring transfusion was 0 (0–1; 0–2), MI 2 (1–4; Pneumonia 86 0.73 0.57–0.88
1–8), pneumonia 4 (2–9; 1–17), PE 5 (3–11; 2–17), UTI 7
(4–14; 2–23), DVT 8 (5–16; 3–20), sepsis 9 (4–16; 2–22), and Deep vein thrombosis 82 0.69 0.54–0.84
SSI 17 (13–22; 9–27). These results are stratified by number Pulmonary embolism 58 0.49 0.37–0.62
of operative levels (for ACDF and PLF) and use of an inter- Myocardial infarction 37 0.31 0.21–0.41
body device (for PLF) in the Supplemental Digital Content
CI indicates confidence interval.
Appendices 4–6, available at: http://links.lww.com/BRS/B19.
Spine www.spinejournal.com 1529
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 EPIDEMIOLOGY
Figure 1. Histograms and hazard cures for timing of complications after anterior cervical decompression and fusion procedures. The figure is
sorted by increasing median day of diagnosis.
of complications. Overall, findings between the ACDF and
PLF cohorts were comparable with most complications hav-
ing similar median days of occurrence. Interestingly, both
cohorts’ complications clustered into an early group (anemia
requiring transfusion, MI, pneumonia, and PE) and a late
group (DVT, sepsis, SSI, and UTI).
UTIs occurred earlier after PLF procedures than after
ACDF procedures (medians of 7 vs. 17 days). There are sev-
eral potential explanations for this discrepancy. First, it is
possible that differences in demographics or medical comor-
bidities between PLF and ACDF patients could contribute to
differential timing. Second, it is possible that differences in
catheterization practices19 between PLF and ACDF patients
could contribute to the difference. The ACS-NSQIP database
does not contain documentation of indwelling or intermittent
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Timing of Complications • Bohl et al
urinary catheterization, so this potential cause could not be
further explored.
The results of this study have several implications for
spine surgery research. The first implication involves the
use of administrative databases, which are the most com-
monly used type of database in spine surgery research.2–8
Examples of such databases include the Nationwide Inpa-
tient Sample (NIS), Kids’ Inpatient Database (KID), and
National Trauma Data Bank (NTDB). Most administrative
databases only capture complications occurring during the
inpatient stay. However, this study’s results indicate that a
substantial proportion of most complications occur after the
hospitalization. As such, these complications are missed in
many spine surgery studies. This issue is a major limitation
of such research.
October 2015
 EPIDEMIOLOGY
Figure 2. Histograms and hazard cures for timing of complications after posterior lumbar fusion procedures. The figure is sorted by increasing
median day of diagnosis.
The second implication relates to the ACS-NSQIP and
other registries with 30-day follow-up.2,10–16 Clearly, the
30-day follow-up afforded by the ACS-NSQIP is superior to
the inpatient-only follow-up afforded by many databases. A
review of the slopes of the hazard curves in Figures 1 and 2
reveals that, for the earlier-occurring complications, the rate
of occurrence has plateaued by the end of the 30-day win-
dow. However, for the later-occurring complications, the rate
of occurrence is still substantial at the end of the 30-day win-
dow. Hence, important proportions of these complications
are likely to be missed even by the ACS-NSQIP.
It is interesting to compare the rates of complications docu-
mented in the present study to the rates of complications doc-
umented in other studies. SSI was documented in the present
study as occurring at rates of 0.41% after ACDF and 1.76%
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Timing of Complications • Bohl et al
after PLF. In a retrospective cohort study of 3,174 patients
undergoing spinal surgery at a single institution, Pull ter
Gunne et al characterized the rate of SSI as 4.16%, substan-
tially higher than the rate documented by the present study.20
This discrepancy can be explained at least in part by the fact
that SSI is one of the later occurring adverse events, meaning
that events are still occurring on the 30th postoperative day.
Although Pull ter Gunne et al captured adverse events occur-
ring after the 30th postoperative day, the present study did
not. Other studies have documented the rate of SSI after spine
surgery as between 0.7% and 12%, somewhat higher than
those documented here, again, consistent with the fact that
those studies may be capturing later-occurring SSIs than the
present study.21–30 In contrast, blood transfusion was docu-
mented in the present study as occurring at rates of 0.53%
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 EPIDEMIOLOGY Timing of Complications • Bohl et al

Figure 3. Summary statistics for timing of complications. Top: After anterior cervical decompression and fusion procedures. The vertical line indi-
cates the median length of stay, which was 1 day. Bottom: After posterior lumbar fusion procedures. The vertical line indicates the median length
of stay, which was 3 days.

after ACDF and 17.45% after PLF. This is reasonably con-
sistent with the findings of Yoshihara et al who documented
the rate of blood transfusion after spinal fusion surgery in the
United State Nationwide Inpatient Sample as 7.1%.31 More-
over, when stratified by cervical versus lumbar procedures,
Yoshihara et al documented the rate as 1.5% after cervical
and 13.0% after lumbar procedures. This early-occurring and
primarily inpatient adverse event is likely captured well by
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the follow-up provided by both the NIS and the ACS-NSQIP,
explaining the reasonably consistent results.
A small yet significant number of the later-occurring com-
plications are noted in the ACDF group before discharge.
This is interesting in the context of the very short median
stay in the hospital for the ACDF procedures. These adverse
events are most likely occurring among patients who had a
prolonged hospital stay due to co-occurrence of a generally
October 2015
 EPIDEMIOLOGY Timing of Complications • Bohl et al

Figure 4. Diagnosis of complications relative to discharge. Top: After anterior cervical decompression and fusion procedures. Bottom: After pos-
terior lumbar fusion procedures.

early-occurring adverse event. As shown in Table 5, there
were a considerable number of patients with multiple com-
plications. If a patient had a prolonged hospital length of
stay due to one of these early-occurring complications, a
later-occurring complication such as SSI would have usually
occurred after discharge might instead occur before discharge.
The limitations of this study are those of the ACS-NSQIP.
First, the ACS-NSQIP does not collect information on spine-
specific or functional outcomes. Second, participation in the
ACS-NSQIP is voluntary on the part of the hospital, so the
ACS-NSQIP is not a truly representative national sample.
Third, the ACS-NSQIP follows patients for only 30 post-
operative days. Fourth, the ACS-NSQIP may have errors in
Spine
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data recording. Fifth, the present data can also be used to
examine risk factors for an array of complications; however,
at least 1 other publication has already addressed this ques-
tion using ACS-NSQIP data,13 so the present study did not
attempt to address this topic. Sixth, the available sample size
was insufficient for the study to provide reliable estimates of
the timing of complications after anterior lumbar interbody
fusion procedures and after combined 360 fusion procedures,
so these were not evaluated. Finally, blood transfusion is only
recorded during the first 3 postoperative days, so these esti-
mates are biased; nevertheless, as Figures 1 and 2 make clear,
the rate of blood transfusion is plateauing by the 3rd postop-
erative day.
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 EPIDEMIOLOGY Timing of Complications • Bohl et al

TABLE 5. Covariance Matrix for Complications After Anterior Cervical Decompression and Fusion*
Anemia Surgical Urinary
Requiring Site Tract Deep Vein Myocardial Pulmonary
Transfusion Pneumonia Infection Infection Sepsis Thrombosis Infarction Embolism
Anemia requiring
—
transfusion
0.044
Pneumonia —
<0.001
Surgical site 0.0133 −0.004
—
infection <0.144 0.626
Urinary tract 0.034 0.096 −0.004
—
infection <0.001 <0.001 0.675
0.068 0.271 0.024 0.171
Sepsis —
<0.001 <0.001 0.008 <0.001
Deep vein 0.048 −0.003 0.055 0.029 0.037
—
thrombosis <0.001 0.733 <0.001 0.002 <0.001
Myocardial 0.029 0.063 −0.002 0.002 0.093 0.002
—
infarction 0.002 <0.001 0.798 0.810 <0.001 0.858
Pulmonary −0.002 −0.002 0.037 0.040 0.051 0.282 −0.001
—
embolism 0.792 0.802 <0.001 <0.001 <0.001 <0.001 0.895
*The first row in each cell is the correlation coefficient. The second row in each cell is the P-value. Bolding indicates statistical significance.

In conclusion, these precisely described postoperative time of greatest risk. Authors, reviewers, and surgeons utilizing
periods enable heightened clinical awareness among spine research on postoperative complications should carefully
surgeons. Spine surgeons should have the lowest threshold consider the impact that the duration of follow-up has on
for testing for each complication during the time period study results.

TABLE 6. Covariance Matrix for Complications After Posterior Lumbar Fusion*

Anemia Urinary Surgical
Requiring Tract Site Deep Vein Pulmonary Myocardial
Transfusion Infection Infection Sepsis Pneumonia Thrombosis Embolism Infarction
Anemia requiring
—
transfusion
Urinary tract 0.067
—
infection <0.001
Surgical site 0.027 0.021
—
infection 0.004 0.021
0.054 0.155 0.190
Sepsis —
<0.001 <0.001 <0.001
0.039 0.034 0.011 0.133
Pneumonia —
<0.001 <0.001 0.222 <0.001
Deep vein 0.039 0.004 0.043 0.069 0.041
—
thrombosis <0.001 0.639 <0.001 <0.001 <0.001
Pulmonary 0.066 0.018 −0.009 0.019 0.037 0.315
—
embolism <0.001 0.048 0.307 0.032 <0.001 <0.001
Myocardial 0.030 0.004 0.004 0.028 0.119 0.014 0.018
—
infarction <0.001 0.663 0.663 0.003 <0.001 0.140 0.054
*The first row in each cell is the correlation coefficient. The second row in each cell is the P-value. Bolding indicates statistical significance.

1534 www.spinejournal.com October 2015

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 EPIDEMIOLOGY
➢ Key Points
Among 12,067 patients undergoing anterior cervi-
cal decompression and fusion procedures, the
median day of diagnosis (and interquartile range;
middle 80%) for anemia requiring transfusion was
0 (0–1; 0–2), myocardial infarction 2 (1–5; 0–15),
pneumonia 4 (2–9; 1–14), pulmonary embolism
5 (2–9; 1–10), deep vein thrombosis 10.5 (7–16.5;
5–21), sepsis 10.5 (4–18; 1–23), surgical site infec-
tion 13 (8–19; 5–25), and urinary tract infection 17
(8–22; 4–26).
Among 11,807 patients undergoing posterior
lumbar fusion procedures, the median day of
diagnosis (and interquartile range; middle 80%)
for anemia requiring transfusion was 0 (0–1; 0–2),
myocardial infarction 2 (1–4; 1–8), pneumonia 4
(2–9; 1–17), pulmonary embolism 5 (3–11; 2–17),
urinary tract infection 7 (4–14; 2–23), deep vein
thrombosis 8 (5–16; 3–20), sepsis 9 (4–16; 2–22),
and surgical site infection 17 (13–22; 9–27).
These precisely described postoperative time pe-
riods enable heightened clinical awareness among
spine surgeons. Spine surgeons should have the
lowest threshold for testing for each complication
during the time period of greatest risk.
Supplemental digital content is available for this article. Direct
URL citations appearing in the printed text are provided in
the HTML and PDF version of this article on the journal’s
Web site (www.spinejournal.com).
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