Obstructive sleep apnea as a risk factor for postoperative complications in lumbar spine surgery: a nationwide inpatient sample database study

Obstructive sleep apnea (OSA) is a prevalent sleep-disordered breathing condition associated with systemic comorbidities; however, its specific impact on postoperative outcomes following lumbar spine surgery (LSS) remains under-characterized. This study aimed to determine the evolving prevalence of OSA among patients undergoing LSS and to evaluate whether OSA serves as an independent risk factor for postoperative complications and resource utilization. A retrospective analysis was conducted using the Nationwide Inpatient Sample (NIS) database from 2016 to 2022, identifying adult patients undergoing LSS. To minimize selection bias and confounding variables, 1:1 propensity score matching (PSM) was performed based on demographics and comorbidities for both the overall cohort and subgroups stratified by surgical complexity (fusion vs. non-fusion). Multivariable binary logistic regression was utilized to assess the association between OSA and perioperative adverse events, length of stay (LOS), total hospitalization charges, and in-hospital mortality, with statistical significance set at P ≤ 0.01. Among 376,834 identified cases, the prevalence of OSA exhibited a significant upward trend, rising from 9.5% in 2016 to 13.6% in 2022. In the overall matched cohort ( n = 89,006), OSA was identified as a significant independent predictor for multiple complications, most notably acute respiratory failure (OR 1.721; 95% CI 1.593–1.859; P < 0.001), alongside hemorrhage/hematoma, acute cerebrovascular disease, acute renal failure, and urinary tract infections. Subgroup analyses demonstrated that the elevated risk of acute respiratory failure persisted robustly across both fusion and non-fusion procedures. Furthermore, within the complex fusion subgroup, OSA independently predicted postoperative shock (OR 1.579; 95% CI 1.173–2.127; P = 0.003) and a paradoxically lower in-hospital mortality (OR 0.582; 95% CI 0.423–0.800; P < 0.001). While OSA was independently associated with prolonged LOS overall, it was not significantly associated with higher total hospitalization charges. OSA is significantly and independently associated with an increased risk of multiple systemic complications following LSS, most notably acute respiratory failure, irrespective of surgical complexity. Despite its association with prolonged hospitalization and elevated vascular and renal morbidities, OSA does not increase in-hospital mortality, a paradox likely driven by intensive postoperative surveillance. These results emphasize the necessity of treating OSA as an active perioperative intervention target rather than a passive comorbidity, highlighting the need for standardized screening and multidisciplinary care to ensure patient safety.