Elsevier

Clinical Neurology and Neurosurgery

Volume 126, November 2014, Pages 137-142
Clinical Neurology and Neurosurgery

Constipation after thoraco-lumbar fusion surgery

https://doi.org/10.1016/j.clineuro.2014.08.036Get rights and content

Highlights

  • Constipation is a major problem for patients who undergo instrumented spine surgery.

  • It is often perceived as more limiting than other restrictions and/or (wound) pain.

  • Despite the use of laxatives, it was noticed in 44% of our patients after fusion surgery.

  • It was associated with longer operation times and higher morphine dosages.

  • One patient developed an adynamic ileus postoperatively.

Abstract

Background

Thoraco-lumbar posterior fusion surgery is a frequent procedure used for patients with spinal instability due to tumor, trauma or degenerative disease. In the perioperative phase, many patients may experience vomiting, bowel irritation, constipation, or may even show symptoms of adynamic ileus possibly due to immobilization and high doses of opioid analgesics and narcotics administered during and after surgery.

Methods

Retrospective single-center study on patients undergoing thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability in 2012. Study groups were built according to presence/absence of postoperative constipation, with postoperative constipation being defined as no bowel movement on postoperative days 0–2.

Results

Ninety-nine patients (39 males, 60 females) with a mean age of 57.1 ± 17.3 years were analyzed, of which 44 patients with similar age, gender, BMI and ASA-grades showed constipation (44.4%). Occurrence of constipation was associated with longer mean operation times (247 ± 62 vs. 214 ± 71 min; p = 0.012), higher estimated blood loss (545 ± 316 vs. 375 ± 332 ml; p < 0.001), and higher mean morphine dosages in the postoperative days 0–7 (the difference being significant on postoperative days 1 (48 mg vs. 30.9 mg, p = 0.041) and 2 (43.2 mg vs. 29.1 mg, p = 0.028). The equivalence dose of morphine administered during surgery was similar (339 ± 196 vs. 285 ± 144 mg; p = 0.286). The use of laxatives in the postoperative days 0–7 was generally high in both study groups, while it was more frequent in patients experiencing constipation. One patient with constipation developed a sonographically confirmed paralytic ileus. Patients with constipation showed a tendency toward longer postoperative hospitalization (7.6 vs. 6.7 days, p = 0.136).

Conclusions

The rate of constipation was high after thoraco-lumbar fusion surgery. Moreover, it was associated with longer surgery time, higher blood loss, and higher postoperative morphine doses. Further trials are needed to prove if the introduction of faster and less invasive surgery techniques may have a positive side effect on bowel movement after spine surgery as they may reduce operation times, blood loss and postoperative morphine use.

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

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