Fat is Bad? Lumbar Discectomy in Patients with High Body Mass Index

Volume 7 | Issue 1 | January-June 2022 | Page: 12-18 | Akshay B Phuse, Sumit Sinha, Nishant Yagnik, Ankush Gupta

DOI: 10.13107/ijs.2020.v07i01.033

Authors: Akshay B Phuse [1], Sumit Sinha [2], Nishant Yagnik [2], Ankush Gupta [2]

[1] Department of Spine Surgery, Atlas Spine and Orthopaedic Hospital, Nagpur, Maharashtra, India.
[2] Department of Spine Surgery, Paras Hospitals, Gurgaon, Haryana, India.

Address of Correspondence
Dr. Akshay B Phuse,
Spine Surgeon, Department of Spine Surgery, Atlas Spine and Orthopaedic
Hospital, Nagpur, Maharashtra, India.


Objective: Spine surgeons are experiencing increased morbidly obese patients with lumbar spine pathology in regular practice. There is a close association between back pain and morbid obesity, particularly due to chronic stresses on the spine. Our objective of this review of literature is to identify the difficulties encountered by the spine surgeons in lumbar spine microdiscectomy and to provide possible solutions for the same. All pre-operative, intra-operative including surgical techniques and post-operative complications with clinical outcomes are taken into consideration.

Methods: obesity was defined as body mass index (BMI) more than 30kg/m2 whereas  Morbidly obese are the people who have BMI more than 40kg/m2 or BMI 35kg/m2 associated with at least 2 co morbid conditions. Keywords were taken as Micro discectomy, lumbar spine disease, morbidly obese, obese, obesity related spine pathology, spinal surgery in obese, Body mass index. This review article examined articles published concerning “lumbar microdiscectomy in obese patients” on Pub Med and Google scholar. We also included some articles related to lumbar fusion surgery in obese patient. Articles in which lumbar spine surgeries operated on non-obese patients and surgeries performed at cervical and dorsal level were excluded. We included 71 articles published on the related topic

Results:  Review illustrated that obese patients were at higher risk of complications at all stages of management. Pre-operatively obese patients showed inferior outcome to conservative management. Health care professionals  are challenged in transportation, imaging, and resuscitation procedures of obese patients  because of large body fat. Intra operatively obese patients have showed increased blood loss, operative time and infection rates. Even surgeries in obese patients were technically demanding. Obese patients demonstrated inferior clinical outcomes, increased complications rates compared to non-obese patients. Minimally invasive spine surgery has shown better and promising results in lumbar discectomy.

Conclusion: lumbar surgeries on obese patients is fraught with multiple challenges starting from preoperative period might through the surgical procedure and rehabilitation With the increasing availability of technology and surgical expertise, MIS has proven to be equally effective, if not better, than traditional lumbar surgeries in this group of patients. Smaller surgical incisions, early mobilization and shorter duration of hospital stay are some of the advantages of this technique

Keywords: Micro discectomy, Lumbar spine disease, Morbidly obese, Obese, Obesity related spine pathology, Spinal surgery in obese, Body mass index.


1. Leboeuf–Yde C, Kyvik KO, Bruun NH. Low back pain and lifestyle. Part II—obesity: information from a population-based sample of 29,424 twin subjects. Spine. 1999 Apr 15;24(8):779-84.
2. Hellsing AL, Bryngelsson L. Predictors of musculoskeletal pain in men: a twenty-year follow-up from examination at enlistment. Spine. 2000 Dec 1;25(23):3080-6.
3. Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011-2014.
4. Gasibat Q, Simbak NB, Barasi SE, Almangoush A. Measuring the Relationship between Obesity and Low Back Pain: A Review Article. American Journal of Medical Sciences. 2017;5(2):35-9.
5. Theodora Lappa RD, Ioannis Kyriazis MD. Obesity Epidemiology and Management-Up to Date Short Review. International Journal of Caring Sciences. 2018;11(1):599-606.
6. Banjare J, Bhalerao S. Obesity associated noncommunicable disease burden. International Journal of Health & Allied Sciences. 2016 Apr 1;5(2):81-.
7. Jakoi AM, Pannu G, D’oro A, Buser Z, Pham MH, Patel NN, Hsieh PC, Liu JC, Acosta FL, Hah R, Wang JC. The clinical correlations between diabetes, cigarette smoking and obesity on intervertebral degenerative disc disease of the lumbar spine. Asian spine journal. 2017 Jun;11(3):337.
8. Epstein NE. More risks and complications for elective spine surgery in morbidly obese patients. Surgical neurology international. 2017;8.
9. Marquez-Lara A, Nandyala SV, Sankaranarayanan S, Noureldin M, Singh K. Body mass index as a predictor of complications and mortality after lumbar spine surgery. Spine. 2014 May 1;39(10):798-804.
10. Patel N, Bagan B, Vadera S, Maltenfort MG, Deutsch H, Vaccaro AR, Harrop J, Sharan A, Ratliff JK. Obesity and spine surgery: relation to perioperative complications. Journal of Neurosurgery: Spine. 2007 Apr 1;6(4):291-7.
11. Lingutla KK, Pollock R, Benomran E, Purushothaman B, Kasis A, Bhatia CK, Krishna M, Friesem T. Outcome of lumbar spinal fusion surgery in obese patients: a systematic review and meta-analysis. The bone & joint journal. 2015 Oct;97(10):1395-404.
12. Bono OJ, Poorman GW, Foster N, Jalai CM, Horn SR, Oren J, Soroceanu A, Ramachandran S, Purvis TE, Jain D, Vira S. Body mass index predicts risk of complications in lumbar spine surgery based on surgical invasiveness. The Spine Journal. 2018 Jul 1;18(7):1204-10.
13. Castle-Kirszbaum MD, Tee JW, Chan P, Hunn MK. Obesity in neurosurgery: a narrative review of the literature. World neurosurgery. 2017 Oct 1;106:790-805.
14. Flippin M, Harris J, Paxton EW, Prentice HA, Fithian DC, Ward SR, Gombatto SP. Effect of body mass index on patient outcomes of surgical intervention for the lumbar spine. Journal of Spine Surgery. 2017 Sep;3(3):349.
15. Puvanesarajah V, Werner BC, Cancienne JM, Jain A, Pehlivan H, Shimer AL, Singla A, Shen F, Hassanzadeh H. Morbid obesity and lumbar fusion in patients older than 65 years: complications, readmissions, costs, and length of stay. Spine. 2017 Jan 15;42(2):122-7.
16. Buerba RA, Fu MC, Gruskay JA, Long III WD, Grauer JN. Obese Class III patients at significantly greater risk of multiple complications after lumbar surgery: an analysis of 10,387 patients in the ACS NSQIP database. The Spine Journal. 2014 Sep 1;14(9):2008-18.
17. Burks CA, Werner BC, Yang S, Shimer AL. Obesity is associated with an increased rate of incidental durotomy in lumbar spine surgery. Spine. 2015 Apr 1;40(7):500-4.
18. Phan K, Lee NJ, Kothari P, Kim JS, Cho SK. Risk factors for readmissions following anterior lumbar interbody fusion. Spine. 2018 Mar 1;43(5):364-9.
19. Akinnusi ME, Pineda LA, El Solh AA. Effect of obesity on intensive care morbidity and mortality: a meta-analysis. Critical care medicine. 2008 Jan 1;36(1):151-8.
20. Burks CA, Werner BC, Yang S, Shimer AL. Obesity is associated with an increased rate of incidental durotomy in lumbar spine surgery. Spine. 2015 Apr 1;40(7):500-4.
21. Green BN, Johnson CD, Haldeman S, Griffith E, Clay MB, Kane EJ, Castellote JM, Rajasekaran S, Smuck M, Hurwitz EL, Randhawa K. A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders. PloS one. 2018 Jun 1;13(6):e0197987.
22. Shahbandar L, Press J. Diagnosis and nonoperative management of lumbar disk herniation. Operative Techniques in Sports Medicine. 2005 Apr 1;13(2):114-21.
23. Eleswarapu AS, Divi SN, Dirschl DR, Mok JM, Stout C, Lee MJ. How Effective is Physical Therapy for Common Low Back Pain Diagnoses?: A Multivariate Analysis of 4597 Patients. Spine. 2016 Aug 15;41(16):1325-9.
24. Bhatia A, Flamer D, Shah PS, Cohen SP. Transforaminal epidural steroid injections for treating lumbosacral radicular pain from herniated intervertebral discs: a systematic review and meta-analysis. Anesthesia & Analgesia. 2016 Mar 1;122(3):857-70.
25. Cushman D, Mattie R, Curtis B, Flis A, McCormick ZL. The effect of body mass index on fluoroscopic time and radiation dose during lumbar transforaminal epidural steroid injections. The Spine Journal. 2016 Jul 1;16(7):876-83.
26. Khoueir P, Black MH, Crookes PF, Kaufman HS, Katkhouda N, Wang MY. Prospective assessment of axial back pain symptoms before and after bariatric weight reduction surgery. The Spine Journal. 2009 Jun 1;9(6):454-63.
27. Lidar Z, Behrbalk E, Regev GJ, Salame K, Keynan O, Schweiger C, Appelbaum L, Levy Y, Keidar A. Intervertebral disc height changes after weight reduction in morbidly obese patients and its effect on quality of life and radicular and low back pain. Spine. 2012 Nov 1;37(23):1947-52.
28. Takenaka S, Mukai Y, Hosono N, Kaito T. Improvement of thoracic myelopathy following bariatric surgery in an obese patient. Case Reports. 2018 Apr 11;2018:bcr-2017.
29. Jain D, Berven SH, Carter J, Zhang AL, Deviren V. Bariatric surgery before elective posterior lumbar fusion is associated with reduced medical complications and infection. The Spine Journal. 2018 Sep 1;18(9):1526-32.
30. Shanbhogue VV, Støving RK, Frederiksen KH, Hanson S, Brixen K, Gram J, Jørgensen NR, Hansen S. Bone structural changes after gastric bypass surgery evaluated by HR-pQCT: a two-year longitudinal study. European journal of endocrinology. 2017 Jun 1;176(6):685-93.
31. Epstein NE. Bariatric bypasses contribute to loss of bone mineral density but reduce axial back pain in morbidly obese patients considering spine surgery. Surgical neurology international. 2017;8.
32. Shaw K, Chen J, Sheppard W, Alazzeh M, Park H, Park DY, Shamie AN. Use of the subcutaneous lumbar spine (SLS) index as a predictor for surgical complications in lumbar spine surgery. The Spine Journal. 2018 Dec 1;18(12):2181-6.
33. Rosenfeld HE, Limb R, Chan P, Fitzgerald M, Bradley WP, Rosenfeld JV. Challenges in the surgical management of spine trauma in the morbidly obese patient: a case series. Journal of Neurosurgery: Spine. 2013 Jul 1;19(1):101-9.
34. Winkelman C, Maloney B, Kloos J. The impact of obesity on critical care resource use and outcomes. Critical Care Nursing Clinics. 2009 Sep 1;21(3):403-22.
35. Le NT, Robinson J, Lewis SJ. Obese patients and radiography literature: what do we know about a big issue?. Journal of medical radiation sciences. 2015 Jun;62(2):132-41.
36. Spitler CA, Hulick RM, Graves ML, Russell GV, Bergin PF. Obesity in the polytrauma patient. Orthopedic Clinics. 2018 Jul 1;49(3):307-15.
37. Kalichman L, Guermazi A, Li L, Hunter DJ. Association between age, sex, BMI and CT-evaluated spinal degeneration features. Journal of back and musculoskeletal rehabilitation. 2009 Jan 1;22(4):189-95.
38. Maruyama T, Grivas TB, Kaspiris A. Effectiveness and outcomes of brace treatment: a systematic review. Physiotherapy theory and practice. 2011 Jan 1;27(1):26-42.
39. Baxi V, Budhakar S. Anesthesia management of a morbidly obese patient in prone position for lumbar spine surgery. Journal of Craniovertebral Junction and Spine. 2010 Jan;1(1):55.
40. Douglass J, Fraser J, Andrzejowski J. Awake intubation and awake prone positioning of a morbidly obese patient for lumbar spine surgery. Anaesthesia. 2014 Feb;69(2):166-9.
41. Neligan PJ. Metabolic syndrome: anesthesia for morbid obesity. Current Opinion in Anesthesiology. 2010 Jun 1;23(3):375-83.
42. Cao J, Kong L, Meng F, Zhang Y, Shen Y. Impact of obesity on lumbar spinal surgery outcomes. Journal of Clinical neuroscience. 2016 Jun 1;28:1-6.
43. Onyekwelu I, Glassman SD, Asher AL, Shaffrey CI, Mummaneni PV, Carreon LY. Impact of obesity on complications and outcomes: a comparison of fusion and nonfusion lumbar spine surgery. Journal of Neurosurgery: Spine. 2017 Feb 1;26(2):158-62.
44. Zhang Y, Liu H, He F, Chen A, Yang H, Pi B. Does tranexamic acid improve bleeding, transfusion, and hemoglobin level in patients undergoing multilevel spine surgery? A systematic review and meta-analysis. World neurosurgery. 2019 Jul 1;127:289-301.
45. Cheriyan T, Maier II SP, Bianco K, Slobodyanyuk K, Rattenni RN, Lafage V, Schwab FJ, Lonner BS, Errico TJ. Efficacy of tranexamic acid on surgical bleeding in spine surgery: a meta-analysis. The Spine Journal. 2015 Apr 1;15(4):752-61.
46. Kim DH, Zaremski J, Kwon B, Jenis L, Woodard E, Bode R, Banco RJ. Risk factors for false positive transcranial motor evoked potential monitoring alerts during surgical treatment of cervical myelopathy. Spine. 2007 Dec 15;32(26):3041-6.
47. Olsen MA, Mayfield J, Lauryssen C, Polish LB, Jones M, Vest J, Fraser VJ. Risk factors for surgical site infection in spinal surgery. Journal of Neurosurgery: Spine. 2003 Mar 1;98(2):149-55.
48. Khan NR, Thompson CJ, DeCuypere M, Angotti JM, Kalobwe E, Muhlbauer MS, Camillo FX, Klimo P. A meta-analysis of spinal surgical site infection and vancomycin powder: a review. Journal of Neurosurgery: Spine. 2014 Dec 1;21(6):974-83.
49. Kang DG, Holekamp TF, Wagner SC, Lehman Jr RA. Intrasite vancomycin powder for the prevention of surgical site infection in spine surgery: a systematic literature review. The Spine Journal. 2015 Apr 1;15(4):762-70.
50. Bakhsheshian J, Dahdaleh NS, Lam SK, Savage JW, Smith ZA. The use of vancomycin powder in modern spine surgery: systematic review and meta-analysis of the clinical evidence. World neurosurgery. 2015 May 1;83(5):816-23.
51. Yamada K, Abe H, Higashikawa A, Tonosu J, Kuniya T, Nakajima K, Fujii H, Niwa K, Shinozaki T, Watanabe K, Sakae T. Evidence-based care bundles for preventing surgical site infections in spinal instrumentation surgery. Spine. 2018 Dec 15;43(24):1765-73.
52. Yao R, Tan T, Tee JW, Street J. Prophylaxis of surgical site infection in adult spine surgery: a systematic review. Journal of Clinical Neuroscience. 2018 Jun 1;52:5-25.
53. Goyal A, Elminawy M, Kerezoudis P, Lu VM, Yolcu Y, Alvi MA, Bydon M. Impact of obesity on outcomes following lumbar spine surgery: a systematic review and meta-analysis. Clinical neurology and neurosurgery. 2019 Feb 1;177:27-36.
54. Emery SE, Daffner SD, France JC, Ellison M, Grose BW, Hobbs GR, Clovis NB. Effect of head position on intraocular pressure during lumbar spine fusion: a randomized, prospective study. JBJS. 2015 Nov 18;97(22):1817-23.

How to Cite this Article: Phuse AB, Sinha S, Yagnik N, Gupta A | Fat is Bad? Lumbar Discectomy in
Patients with High Body Mass Index | International Journal of Spine | January-June 2020; 7(1): 12-18.

(Abstract Text HTML) (Download PDF)