Does Rural Residence Lead to Worse Outcomes After Adult Spinal Deformity Surgery?

BACKGROUND AND OBJECTIVES: In patients undergoing adult spinal deformity surgery, we aimed to evaluate the relationship between rural residence and: (1) perioperative outcomes, (2) postoperative alignment, and (3) complications. METHODS: A retrospective cohort study (2009-2023) was performed for patients with the following inclusion criteria: ≥5-level fusion, sagittal/coronal deformity, and 2-year follow-up. Primary exposure was rural residence based on Economic Research Service designated Rural-Urban Commuting Area codes: 1 to 6-urban, 7 to 10-rural. Primary outcomes were: (1) perioperative outcomes, (2) postoperative alignment, including sagittal vertical axis, coronal vertical axis, and L1-pelvic angle within target range, and (3) complications. Multivariable regression controlled for age, sex, body mass index, preoperative sagittal vertical axis/coronal vertical axis, and operative time. RESULTS: Of 288 patients, 36 (13%) were rural residents. Rural patients had a higher body mass index (32 ± 9 vs 28 ± 6, P = .011) and diabetes rate (33% vs 17%, P = .024). Preoperatively, rural patients had lower hematocrit (35.4 ± 6.5 vs 37.4 ± 5.2, P = .048) and required more frequent (78% vs 58%, P = .023; odds ratio = 3.1, 95% CI: 1.1-8.5, P = .031) and greater (4 ± 5 vs 2 ± 4 units, P = .019) intraoperative transfusions. Postoperatively, rural residents had higher sagittal vertical axis ≥5 cm (69% vs 48%, P = .037; β = 16.1, 95% CI: 0.0-32.2, P = .050), with no significant association with postoperative coronal malalignment (25% vs 19%, P = .688). No difference was seen in rates of complications, or reoperation. CONCLUSION: In patients undergoing adult spinal deformity surgery, rural residence was independently associated with increased intraoperative blood transfusions and worse postoperative sagittal alignment. These findings suggest that socioeconomic and geographic factors may play a role in surgical outcomes, potentially because of disparities in preoperative health status and access to perioperative care.