Oral Presentation 50th International Society for the Study of the Lumbar Spine Annual Meeting 2024

Risk factors of postoperative ileus in corrective spinal surgery: The analysis of the retrocrural space (#MP-14d)

SHUHEI OHYAMA 1 , Toshiaki Kotani 1 , Tsuyoshi Sakuma 1 , Yasushi Iijima 1 , Tsutomu Akazawa 2 , Kazuhide Inage 3 , Shiga Yasuhiro 3 , Shohei Minami 1 , Seiji Ohtori 3
  1. Department of Orthopedic Surgery, Seirei Sakura Citizen Hosipital, Sakura, CHIBA, Japan
  2. Department of Orthopedic Surgery, St. Marianna University School of Medicine, Kawasaki
  3. Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University., Chiba-city, Chiba

Introduction: Gastrointestinal complications are frequent after spinal corrective surgery, such as postoperative ileus (POI).1,2 POI after spinal surgery is reportedly caused by multiple factors.3,4 Opioid doses and compression of the celiac plexus and sympathetic nerves are one of the causes of POI. In the gastrointestinal field, median arcuate ligament syndrome (MALS) is a disease in which the celiac plexus is chronically compressed by the median arcuate ligament (MAL) and is associated with paralytic ileus.5

The retrocrural space (RCS) is a triangular region delimited anteriorly and laterally by MAL and posteriorly by the anterior vertebral wall.6 The RCS area can change after corrective spinal surgery, and reduction in this area may be associated with compression of structures, such as the celiac plexus and sympathetic nerves.6 However, it is unclear whether changes in the RCS area are associated with the development of POI.

This study aimed to determine whether a reduction in the RCS area is a risk factor for POI.

Methods: Overall, 100 patients (67.5±8.3 years; 9 males and 91 females) with ASD treated with spinal corrective surgery were enrolled in this study. Spinal parameters, including thoracolumbar kyphosis (TLK), and RCS area were measured pre- and postoperatively. The change (Δ) in spinal parameters was calculated. The percent change between pre- and postoperative RCS areas was calculated as ΔRCS. The cumulative opioid doses were calculated and compared using standardized converted morphine milligram equivalent (MME) values. Patients were identified as having POI if they exhibited both gastrointestinal symptoms and radiographic findings. In addition, patients with no radiographic findings but only gastrointestinal symptoms were classified as postoperative subileus (POSI). Each parameter was compared between patients with and without POI. Multivariate logistic regression analysis was performed with POI as the dependent variable. Similar analyses were performed for the POSI group.

Results: The incidence rates of POI and POSI were 11.0% and 30.0%. The RCS area was significantly smaller in the POI group than in the non-POI group (P < 0.001). Multivariate logistic regression analysis revealed that ΔTLK and ΔRCS were risk factors for POI. The MME was significantly greater in the POSI group than in the non-POSI group (p < 0.001). Multivariate logistic regression analysis revealed that greater MME was significantly associated with the development of POSI.

Discussion: Correction of spinal alignment can change the tension of the MAL applied to the structures in the RCS, which is reflected in the RCS area.6 In particular, correction of the thoracolumbar junction was strongly correlated with a reduction in the RCS area.6 TLK has been reported to be associated with POI development, which is consistent with the results of this study.7 This study is the first to describe the possibility that the development of POI after corrective spinal surgery is due to compression of the celiac plexus by the MAL. In conclusion, RCS is a risk factor for POI development after corrective spinal surgery in patients with ASD. Overcorrection of the thoracolumbar junction should be avoided to prevent POI.

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