Blood loss during three column osteotomies: influence on outcomes and mitigation strategies

Three column osteotomies (3CO) are a powerful tool for the correction of rigid sagittal spinal deformities. However, 3CO surgeries are technically demanding procedures that are associated with prolonged operative times, large amounts of intraoperative blood loss, and high rates of post-operative neurological and medical complications. The purpose of this retrospective cross-sectional study is to delineate the effects of blood loss, blood transfusion, and tranexamic acid use on perioperative outcomes following 3CO.

Patients undergoing 3CO between 2014 and 2021 were identified using current procedural terminology (CPT) codes, and charts were reviewed for demographics, surgical characteristics, and post-operative length of stay (LOS). Statistical analysis included T-tests for continuous characteristics and χ² testing for categorical characteristics. Regression models were used to further investigate relationships between outcomes and variables of interest.

Forty-two patients met inclusion criteria. Increased intensive care unit (ICU) LOS was positively correlated with increased operative length (P=0.02), percent estimated blood volume (EBV) lost (P=0.02), and number of units of red blood cell transfusion (P<0.001). Increased hospital LOS was associated with increased number of intraoperative blood transfusions (P=0.01). Linear regression analyses controlling for age, gender, and American Society of Anesthesiologists (ASA) class showed that each 21% increase in EBV loss was associated with a one day increase in ICU LOS (P=0.01). Similarly, each additional unit of packed red blood cells transfused was associated with 0.728 day increase in hospital LOS.

Increased intraoperative blood loss was associated with longer ICU stays. Red blood cell transfusions were also associated with increased hospital and ICU LOS. No variables of interest related to intraoperative blood loss or blood transfusion were associated with readmission or reoperation at any time point. These findings highlight the need for continued focus on surgical techniques and adjuncts that can minimize blood loss and transfusion requirements.