Adverse Impact of Diabetes on Spine Fusion and Patient-Reported Outcomes: A Systematic Review and Meta-Analysis

Michael P Steinmetz; John E O'Toole; James S Harrop; Gonzalo Mariscal; Christopher D Chaput; Paul M Arnold; W Bradley Jacobs; Christopher D Witiw; Rick C Sasso

doi:10.1097/BRS.0000000000005396

Adverse Impact of Diabetes on Spine Fusion and Patient-Reported Outcomes: A Systematic Review and Meta-Analysis

Spine (Phila Pa 1976). 2025 May 19. doi: 10.1097/BRS.0000000000005396. Online ahead of print.

Authors

Michael P Steinmetz¹, John E O'Toole², James S Harrop³, Gonzalo Mariscal⁴, Christopher D Chaput⁵, Paul M Arnold⁶, W Bradley Jacobs⁷, Christopher D Witiw⁸, Rick C Sasso⁹

Affiliations

¹ Neurological Institute, Department of Neurosurgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, US.
² Rush University Medical Center, Chicago, Illinois, US.
³ Departments of Neurological and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, US.
⁴ Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, Valencia, ES.
⁵ Department of Orthopedics, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, US.
⁶ Department of Neurological Surgery, Loyola University Chicago, Chicago, Illinois, US.
⁷ Calgary Spine Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, CA.
⁸ Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, CA.
⁹ Dept Orthopaedic Surgery, Indiana University School of Medicine, Indiana Spine Group, Carmel, Indiana, US.

PMID: 40386865
DOI: 10.1097/BRS.0000000000005396

Abstract

Study design: Systematic review and meta-analysis.

Purpose: This meta-analysis aimed to provide a comprehensive evaluation of the impact of diabetes on spinal surgery outcomes.

Summary of background data: Diabetes Mellitus is believed to be associated with an increased risk of adverse events during spinal surgery. With the increasing prevalence of diabetes and the increasing number of degenerative spinal procedures, understanding postsurgical expectations and optimal care is essential.

Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted across PubMed, EMBASE, Scopus, and the Cochrane Library, selecting studies comparing diabetes and without diabetes who underwent spine fusion surgeries. 18 studies with 118,617 patients were included. The outcomes of interest were the risk of the incidence of spinal pseudoarthrosis and PROMs, including Visual Analog Scale (VAS), Oswestry Disability Index (ODI), EQ-5D and SF-12/36 score. Odds ratios (OR) were calculated for dichotomous variables, mean differences (MD) for continuous variables and Standard Mean Differences (SMD) for continuous variables not sharing the same scale or units. Random effects were used if there was evidence of statistical heterogeneity.

Results: Eighteen studies, comprising 118,617 patients, were included in the final analysis. Diabetes patients had a higher incidence of pseudoarthrosis at the lumbar spine (OR 1.13, 95%CI 1.02 to 1.25, P<0.05). Patients with diabetes also reported increased VAS back/neck pain scores (SMD 0.21, 95%CI 0.14 to 0.28, P<0.001) and worse ODI outcomes (MD 3.96, 95%CI 3.10 to 4.82, P<0.001), EQ-5D (MD -0.06, 95%CI -0.08 to -0.03, P<0.001) and SF-12/36 scores (SMD -2.70, 95%CI -4.99 to -0.41, P<0.05).

Conclusion: Patients with diabetes who underwent spinal surgery had a higher incidence of pseudoarthrosis and worse functional outcomes compared to non-diabetic patients. These findings underscore the need for targeted clinical management and preventive strategies for patients with diabetes undergoing these procedures.

Level of evidence: III.

Keywords: clinical management; diabetes; incidence; meta-analysis; nonunion; patient-reported outcomes; pseudoarthrosis; spine fusion; surgery; systematic review.