Constipation after thoraco-lumbar fusion surgery
Introduction
Thoraco-lumbar fusion surgery is a frequent procedure used for patients with spinal instability due to trauma or degenerative disease. Even though the literature regarding gastrointestinal morbidity after spine surgery is scarce, a significant amount of patients experience vomiting, bowel irritation, constipation, or may even show symptoms of adynamic ileus in the postoperative period, despite generous use of laxatives [1], [2], [3], [4]. In a retrospective review of 253 spinal procedures in children, the incidence of postoperative gastrointestinal morbidity was reported to be 77.9%, including emesis (50.6%) and paralytic ileus (42%) [5]. These frequently encountered complaints are likely to be due to pain-related immobilization, high doses of morphine analgesics and narcotics administered during major spine surgery, as well as pain-related activation of the sympathetic system. In addition, intraoperative irritation of sympathetic splanchnic nerves may contribute to paralytic bowel dysfunction [6]. Adequate analgesia, however, is an essential part of the perioperative management in spine surgery and the use of morphine is often unavoidable. Constipation as frequent side effect of morphine therapy is well known by most physicians and nursing staff [2], [7].
Despite timely and adequate prevention, constipation is common on the neurosurgical wards [3], [4], [8], [9]. It has been our observation that the rate of constipation was higher in patients with spinal surgeries than with cranial surgeries. Indeed spinal surgery increased the risk of postoperative gastrointestinal morbidity in a previously published study [5]. In our clinical practice, a considerable number of patients rate their postoperative bowel dysfunction, especially constipation, as more restrictive than the functional restriction from postoperative pain.
This striking impact of constipation on the subjective well-being of our patients prompted us to undertake the current study, determine the rate of constipation after thoraco-lumbar spinal fusion surgery and identify factors associated with it. We hypothesize that constipation is common amongst patients receiving thoraco-lumbar spinal fusion surgery and that the complexity and length of surgery are important predisposing factors.
Section snippets
Methods
Patient data was retrospectively collected from all patients undergoing thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability at the Department of Neurosurgery of the Kantonsspital St. Gallen in 2012. Informed consent was obtained from all patients. All clinical charts were reviewed. In order to capture the gastrointestinal parameters accurately, we reviewed the nursing records as well. Our nursing staff keep detailed daily records on intake and output, including
Results
Ninety-nine patients (39 males, 60 females) with a mean age of 57.1 ± 17.3 years were analyzed. Forty-four patients (44.4%) with matchable age, gender, ASA-grade, BMI, as well as preoperative morphine and laxative intake showed constipation (Table 1). Indications for surgery and surgery-related parameters are depicted in Table 2. In most cases, posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) procedures were performed, however—in each one patient with or
Discussion
The present study demonstrates that the rate of constipation is high in patients undergoing thoraco-lumbar fusion surgery for degenerative spinal instability (44%), despite a high percentage of patients ingesting laxatives (a lot of them multiple types (Fig. 1 and Table 5)). Overall, the presence of constipation was associated with longer operation times and higher EBL (Table 2). Our hypothesis that constipation was associated with higher amounts of morphine derivates administered during the
Conclusions
The rate of constipation is high after thoraco-lumbar fusion surgery and was associated with longer surgery time, higher intraoperative blood loss, and higher morphine dosages in the postoperative period. Laxatives were frequently administered but seemed only little helpful to prevent constipation. Further trials are needed to investigate if the implementation of a standardized postoperative protocol, the use of minimal invasive procedures in spine surgery and the implementation of epidural
References (26)
- et al.
Constipation and defecation pattern the first 30 days after hip fracture
Int J Nurs Pract
(2014) - et al.
Opioid induced bowel disease: a twenty-first century physicians’ dilemma. Considering pathophysiology and treatment strategies
Curr Gastroenterol Rep
(2013) - et al.
Does a preoperative bowel preparation reduce bowel morbidity and length of stay after scoliosis surgery? A randomized prospective study
J Pediatr Orthop
(2013) - et al.
A randomized prospective evaluation of 3 techniques of postoperative pain management after posterior spinal instrumentation and fusion
Spine
(2013) - et al.
Gastrointestinal morbidity following spinal surgery in children
J. Bone Joint Surg
(2005) - et al.
Postoperative care pain management
- et al.
Opioid-induced bowel dysfunction: pathophysiology and management
Drugs
(2012) - et al.
Postoperative analgesia after anterior correction of thoracic scoliosis: a prospective randomized study comparing continuous double epidural catheter technique with intravenous morphine
Spine
(2006) - et al.
Double epidural catheter with ropivacaine versus intravenous morphine: a comparison for postoperative analgesia after scoliosis correction surgery
Anesthesiology
(2005) Definitions, epidemiology, and impact of chronic constipation
Rev Gastroenterol Disord
(2004)
Identifying constipation risk in neurosurgery patients
PNN
Postoperative constipation risk assessment in Turkish orthopedic patients
Gastroenterol Nurs
Adverse event recording post hip fracture surgery
Ir Med J
Cited by (23)
The risk factors for postoperative ileus following posterior thoraco-lumbar spinal fusion surgery
2019, Clinical Neurology and NeurosurgeryCitation Excerpt :Thus, the duration of PI greater than 48 h was considered to be pathologic [6,7]. In this study, PI was defined as no tolerance of an oral diet and missing bowel movements / passage of flatus or stool until postoperative day 2 [8,9]. The following parameters were recorded: patient demographics (gender, age and body mass index), comorbidities (diabetes mellitus, high blood pressure, previous abdominal and spine surgery), surgery related factors (surgical indications, duration of preoperative dietary restriction, surgical type, number of fusion segments, length of skin incision, surgical duration, blood loss and blood transfusion), postoperative factors (duration of postoperative dietary restriction, date of first gas passage, date of first bowel movement, vomiting, preoperative and postoperative day three laboratory findings, length of postoperative hospital stay).
Outcomes following minimally invasive lateral transpsoas interbody fusion for degenerative low grade lumbar spondylolisthesis: A systematic review
2018, Clinical Neurology and NeurosurgeryCitation Excerpt :Traditional surgical treatment options have ranged from decompression alone or decompression with fusion (anterior or posterior) with or without listhesis correction to multilevel fusion for deformity correction [6,7]. Within the last decade, the advent of modern minimally invasive surgery (MIS) techniques has shortened operative times while minimizing blood loss, soft tissue dissection, muscle damage as well as postoperative incisional pain [33]. Compared to patients with degenerative disc disease, adjacent segment disease and post-laminectomy syndrome, patients with degenerative spondylolisthesis have been reported to have greater improvements in disability after lumbar fusion [23,34].
Ultrasound-guided Stellate Ganglion Block Improves Gastrointestinal Function After Thoracolumbar Spinal Surgery
2017, Clinical TherapeuticsCitation Excerpt :Thoracolumbar spinal surgery is a frequent procedure undertaken for patients with spinal trauma, tumor, or degeneration. In the perioperative phase, 36% to 78% of patients have gastrointestinal morbidity, including emesis, bowel irritation, abdominal bloating, constipation, and even paralytic ileus.1–5 These complications are possibly attributable to the imbalance between the sympathetic and parasympathetic systems after trauma and surgical manipulations.5,6
Development and validation of a nomogram to predict the risk of constipation after lumbar interbody fusion surgery
2024, Archives of Orthopaedic and Trauma SurgeryDetermining the learning curve for percutaneous endoscopic lumbar interbody fusion for lumbar degenerative diseases
2023, Journal of Orthopaedic Surgery and ResearchEffects of Abdominal Massage for Preventing Acute Postoperative Constipation in Hip Fractures: A Prospective Interventional Study
2023, CiOS Clinics in Orthopedic Surgery