Current Evidence on Spinal Fusion in Patients with Sickle Cell Disease

Introduction: Patients with sickle cell disease (SCD) are at increased risk for developing spinal pathologies, including osteomyelitis, spondylodiscitis, and vertebral fractures. The interplay of vaso-occlusive crises, avascular necrosis, and a compromised immune response complicates surgical management and postoperative outcomes. To our knowledge, this is the first narrative review to evaluate current evidence of fusion outcomes, infection rates, and postoperative complications in patients with SCD.

Methods: A comprehensive literature review was conducted using PubMed to identify relevant articles, with search terms including combinations of “sickle cell anemia”, “sickle cell disease”, and “hemoglobin S” with “spinal fusion”. Two reviewers independently assessed the literature to identify studies that met the inclusion criteria. Following adjudication, eleven key studies were selected, highlighting outcomes of posterior cervical and lumbar fusions, perioperative infection risks, and challenges posed by specific pathogens.

Results: Infections in SCD patients undergoing spinal surgery are predominantly caused by Staphylococcus aureus and Salmonella spp. These pathogens contribute to elevated risks of postoperative osteomyelitis and vertebral abscess formation. Isolated single-level posterior lumbar interbody fusions are associated with greater complications in SCD compared to non-SCD patients, including transfusion (OR 17.69), pneumonia (OR 6.30), sepsis (OR 4.86), and aggregated adverse events (OR 3.87). Compared to non-SCD, SCD patients with 1-3 level lumbar fusions have higher rates of neurovascular compromise (p < 0.01), pneumonia (p < 0.01), and urinary tract infections (p < 0.01), whereas posterior cervical fusions demonstrate the highest incidence of pulmonary embolism (OR 7.37). Postoperative infections remain a considerable challenge across these procedures. Furthermore, low bone density and reduced vertebral body dimensions in SCD patients complicate surgical hardware placement. Despite these challenges, early aggressive neurosurgical intervention has shown promise in improving outcomes, especially in younger patients with well-controlled SCD.

Conclusion : Surgical intervention in SCD patients poses considerable perioperative risks, primarily from infection and compromised bone healing. Effective infection control and meticulous preoperative planning are essential to improve outcomes and minimize complications in this high-risk population.