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Study Intervention Complication Total number

Males, number (%)

Females, number (%)

Total complications

Males–complications, number (%)

Females–complications, number (%)

Findings

Bazaz et al. (2002) [2]

Anterior cervical spine surgery

Dysphagia 221 115 (52.0*) 106 (48.0*)

37* 13 (35.1*) 24 (64.9*) Males at decreased risk for incidence of dysphagia at 6 months postoperatively (p = 0.023)

Cahill et al. (2009) [3]

Anterior cervical spinal fusion

All complications

27,067 13,022* (48.1*)

14,055* (51.9*)

1321* 711 (54.0) 610 (46.0) Females at decreased odds for all complications; OR, 0.78 (95% CI, 0.7–0.87)

Posterior cervical spinal fusion

All complications

2869 1619*

(56.4*)1249*

(43.5*)286* 165 (58.0) 121 (42.0) No significant

difference in overall complication rate between sexes; OR, 0.94 (95% CI, 0.73–1.2)

Thoracic spinal fusion

All complications

3257 1600* (49.1*)

1657* (50.9*)

561* 315 (56.0) 246 (44.0) Females at decreased odds for all complications; OR, 0.71 (95% CI, 0.59–0.85)

Lumbar spinal fusion

All complications

36,807 15,931*

(43.3*)20,888* (56.8*)

2613* 1155 (44.0) 1458 (56.0) No significant difference in overall complication rate

Appendix 3. Summary of findings from 45 studies describing postoperative complications by sex

between sexes; OR, 0.96 (95% CI, 0.87–1.04)

Chen et al. (2009) [4]

Spine surgery Surgical site infection

195* NR NR 27* NR NR No significant difference in surgical site infection rate between sexes; OR, 1.305 (95% CI, 0.605–2.816)

Cloyd et al. (2010) [5]

Multilevel spinal fusion surgery

Major complications

124 56 (45.2) 68*(54.8*) 25 NR NR Males at increased odds of major complications in multivariate analysis; OR, 4.56 (95% CI, 1.28–16.24)

Cloyd et al. (2010) [5]

Reoperation 124 56 (45.2) 68*(54.8*) 26* NR NR No significant difference in reoperation rate between sexes; OR, 0.94 (95% CI, 0.41–2.17)

Cloyd et al. (2010) [5]

All complications

124 56 (45.2) 68*(54.8*) NR NR NR No significant difference in overall complication rate between sexes; OR, 1.44 (95% CI, 0.71–2.94)

Danto et al. (2012) [6]

Cervical discectomy

Dysphagia 149 80 (53.0) 69 (46.0) 18 NR NR No significant difference in rate

of dysphagia and dysphonia combined between sexes; OR, 1.3 (95% CI, 0.5–3.2)

Danto et al. (2012) [6]

Cervical discectomy

Dysphonia 149 80 (53.0) 69 (46.0) 8 NR NR No significant difference in rate of dysphagia and dysphonia combined between sexes; OR, 1.3 (95% CI, 0.5–3.2)

Deyo et al. (1992) [7]

Lumbar spine surgery

All complications

18,122 10610 (59.0)

7512 (41.0)

1649* 934*(56.6*) 721*(43.7*) No significant difference in total complication rate between sexes, but females at decreased risk of combined complications and prolonged hospitalization; RR, 0.87 (95% CI, 0.77–0.97)

Deyo et al. (2010) [8]

Lumbar spinal stenosis surgery

Cardio-pulmonary complications or stroke

32,152 14,909 (46.0*)

17,243 (54.0)

984 472 (48.0*) 512 (52.0*) No significant difference in cardiopulmonary complication or stroke rate between sexes (p

> 0.05)Deyo et al. (2010) [8]

Wound complications

32,152 14,909 (46.0*)

17243 (54.0)

398 179 (45.0*) 219 (55.0*) No significant difference in wound complication rate between sexes(p > 0.05)

Fang et al. (2005) [9]

Spinal surgery Infection 120 50 (42.0*) 70 (58.0*) 43 21 (48.8*) 22 (51.2*) No significant difference in infection rate between sexes (p = 0.25); OR, 1.58 (95% CI, 0.73–3.4)

Fineberg et al. (2013) [16]

Cervical spine surgery

Aspiration 20,2694 99,320* (49.0*)

103,374* (51.0)

1080 598*(55.4) 482*(44.6) Males at increased odds of aspiration (p < 0.001); OR, 1.4 (95% CI, 1.2–1.6)

Lumbar spinal fusion

Gastrointestinal hemorrhage

220,522 NR NR 310 NR NR Males at increased odds of GI hemorrhage (p < 0.001); OR, 2.3 (95% CI, 1.7–3.0)

Pulmonary embolism

577415 NR NR 1042 NR NR Males at increased odds of pulmonary embolism (p = 0.006); OR, 1.3 (95% CI, 1.1–

1.5); study DVT data did not meet our inclusion criteria

Perioperative cardiac complication

214,900 105,360*

(49.0*)109,540* (51.0*)

857 479*(55.9*) 378*(44.1) Females at decreased risk for perioperative cardiac complications (p < 0.0005) in univariate analysis

Perioperative cardiac complication

578,457 285,156* (49.0*)

293,301* (51.0*)

3848 1874*(48.7*) 1974*(51.3) Males at increased odds of perioperative cardiac complications (p < 0.0005); OR, 1.2 (95% CI, 1.1–1.3)

Anterior lumbar fusion

Postoperative ileus

19,762 8930*

(45.0*)10,832* (55.0*)

1481 813*(54.9*) 668*(45.1) Males at increased odds of postoperative ileus with this surgery (p < 0.001) and for all lumbar fusion surgeries combined (p < 0.001); OR, 1.9 (95% CI, 1.8–2.0)

Fineberg et al. Posterior Postoperative 18,2801 79,687* 103,114* 4749 2769*(58.3*) 1980*(41.7) Males at

(2014) [12] lumbar fusion ileus (44.0*) (56.0*) increased odds of postoperative ileus with this surgery (p < 0.001) and for all lumbar fusion surgeries combined (p < 0.001); OR, 1.9 (95% CI, 1.8–2.0)

Anterior/ posterior lumbar fusion

Postoperative ileus

17,959 8251* (46.0*) 9708*

(54.0*)1511 817*(54.1*) 694*(45.9) Males at

increased odds of postoperative ileus with this surgery (p < 0.001) and for all lumbar fusion surgeries combined (p < 0.001); OR, 1.9 (95% CI, 1.8–2.0)

Delirium 57,8457 285,758* (49.4*)

292,699* (50.6)

4857 2161*(44.5*) 2696*(55.5) No significant difference between sexes in postoperative delirium rate in multivariate analysis

Friedman et al. (2007) [17]

Laminectomy Surgical site infection

123* 80*(65.0*) 43*(35.0*) 41 24 (59.0) 17*(41.0*) No significant difference in surgical site

infection rate between sexes (p = 0.29); OR, 0.66 (95% CI, 0.30–1.43)

Garg et al. (2010) [18]

Anterior lumbar fusion

Vascular injury

212 92*(43.4*) 120 (56.6) 13 10 (76.9*) 3 (23.1*) Females at decreased risk for vascular injury (p = 0.013)

Goz et al. (2014) [19]

Spinal fusion Venous thromboembolic events

710,154 331,926 (46.7*)

378,228 (53.3*)

3514* 1925*(54.8*) 1589*(45.2*) Females at decreased odds of VTE (p = 0.0465); OR, 0.78 (95% CI, 0.62–1)

Gruskay et al. (2014) [21]

ACDF Major complications

2164 1057 (49.1) 1107 (50.9) 71 46*(64.8*) 25*(35.2*) Males at increased odds of major complications in multivariate analysis (p = 0.040); OR, 1.756 (95% CI, 1.027–3.003)

Hoffmann et al. (2013) [22]

Posterolateral fusion with rhBMP-2 implant

Nonunion requiring reoperation

1158 468 (40.4) 690 (59.6) 41 24 (58.5) 17 (41.5) Males at increased odds for nonunion; OR, 2.08 (95% CI, 1.13–3.83)

Posterolateral fusion with rhBMP-2

Seroma requiring reoperation

1158 468 (40.4) 690 (59.6) 32 12 (37.5) 20 (62.5) Statistical difference in seroma rate

implant between sexes NR

Posterolateral fusion with rhBMP-2 implant

Infection requiring reoperation

1158 468 (40.4) 690 (59.6) 26 6 (23.1) 20 (76.9) No significant difference in infection rate between sexes (p = 0.2198).

Horwitz and Curtin (1975) [23]

Laminectomy Wound infections (sepsis)

496 333*(67.0*) 163 (33.0) 16 15 (93.8*) 1 (6.3*) Females at decreased risk for wound infection (significance level not reported)

Javalkar et al. (2011) [24]

Reoperation 335 167 (49.9) 168 (50.1) 44 27 (61.4) 17 (38.6) No significant difference in reoperation rate between sexes; OR, 1.2 (95% CI, 0.586–2.635)

King et al. (2009) [26]

Degenerative cervical spine disease surgery

Reoperation 12,338 6693 (54.0) 5645 (46.0)

688 405 (59) 283 (41) Males at increased odds of reoperation (p = 0.038); OR, 1.17

Koutsoumbelis et al. (2011) [27]

Spine surgery Surgical site infection

252 109 (43.3*) 143 (56.7*) 84 29 (34.4) 55 (65.6) No significant difference in surgical site infection rate between sexes in multivariate analysis (p = 0.07); OR, 1.95

(95% CI, 0.95–4.01)

Kurtz et al. (2012) [28]

Lumbar fusion

Infection 15,674 5524 (35.2) 10,150 (64.8)

1355* NR NR No significant difference in infection rate between sexes (p = 0.2198)

Lee et al. (2007) [29]

Anterior cervical spine surgery

Dysphagia 310 158 (51.0*) 152 (49.0*)

48* 17* (35.0*) 31* (65.0*) Females at increased risk for dysphagia 12 months postoperatively (p < 0.02); prevalence ratio = 1.91 (95% CI, 1.1–3.33)

Lee et al. (2012) [30]

Spine surgery Medical complications

1591 914 (57.0) 677 (43.0) 676 NR NR Females at decreased risk of pulmonary complications only in multivariate analysis (p = 0.024); RR, 0.65 (95% CI, 0.43–0.94)

Lykissas et al. (2014) [31]

Lateral lumbar interbody fusion

Postoperative anterior thigh/groin pain

451 179 (40.0*) 272 (60.0*)

241* 45* (19.0*) 196* (81.0*) Males at decreased odds of anterior thigh/groin pain immediately postoperatively (p = 0.007); OR,

0.525 (95% CI, 0.329–0.838)

Motor deficit 451 179 (40.0*) 272 (60.0*)

139* 38* (27.0*) 101* (73.0*) No significant difference in motor deficit rate between sexes immediately postoperatively (p = 0.913); OR, 0.974 (95% CI, 0.604–1.569)

Sensory deficit

451 179 (40.0*) 272 (60.0*)

200* 59* (30.0*) 141* (70.0*) No significant difference in sensory deficit rate between sexes immediately postoperatively (p = 0.854); OR, 1.043 (95% CI, 0.665–1.635)

Marquez-Lara et al. (2014) [33]

Lumbar fusion

Cerebral vascular accidents

264,891 115,487* (43.6*)

149,404* (56.4*)

340 143* (42.1*) 197* (57.9) No significant difference in CVA rate between sexes (p = 0.569)

Nandyala et al. (2014) [35]

Spinal fusion Visual loss 541,485 252,339* (46.6*)

289,146* (53.4*)

105 56* (53.3*) 49* (46.7) No significant difference in visual loss rate between sexes (p = 0.23)

Nassr et al. (2012) [36]

Multilevel cervical

C5 palsy 630 338 (53.7*) 292 (46.3*)

42 29 (69.0*) 13 (31.0*) Females at decreased risk of

decompression C5 palsy (p = 0.05)

Ogelsby et al. (2013) [37]

Deep vein thrombosis

273,396 NR NR NR NR NR Males at increased odds of DVT (p < 0.0005); OR, 1.5 (95% CI, 1.3–1.8)

Ogelsby et al. (2013) [37]

Pulmonary embolism

273,396 NR NR NR NR NR Males at increased odds of PE (p < 0.0005); OR, 1.8 (95% CI, 1.4–2.4)

Pugely et al. (2014) [39]

30-day readmission

15,668 7964*(50.8*) 7704*(49.2*) 695 323*(46.5*) 372*(53.5) Statistical difference in 30-day readmission rate between sexes in multivariate analysis NR

Pull ter Gunne et al. (2009) [40]

Spinal surgery Clinical infection

3174 1273 (40.1) 1901 (59.9)

132 58 (43.9*) 74 (56.1*) No significant difference in clinical infection rate between sexes (p = 0.359)

Riley et al. (2005) [42]

ACDF Dysphagia 454 237* (52.2) 217*(47.8) 128 NR NR No significant difference in dysphagia rate between sexes (p = 0.915); OR, 1.02 (95% CI, 0.68–1.55)

Scheer et al. (2013) [43]

Adult spinal deformity surgery

Reoperation 268† 38 (14.2*) 231 (86.2*)

46 8 (17.4*) 38 (82.6*) Statistical difference in reoperation rate between sexes NR

Schnee et al. (1997) [44]

Iliac crest harvest for anterior cervical fusion

Infection/ dehiscence

144 73 (50.7*) 71 (49.3*) 9* 1 (11.1*) 8 (88.9*) Males at decreased risk of infection/dehiscence (p < 0.00001)

Schoenfeld et al. (2011) [50]

Spinal surgery Major complications

3475 1871 (54.0) 1604 (46.0)

179 NR NR No significant difference in major complication rate between sexes (p = 0.5); OR, 1.11 (95% CI, 0.82–1.5)

Spinal surgery Minor complications

3475 1871 (54.0) 1604 (46.0)

128 NR NR Females at increased odds of minor complications (p = 0.025); OR, 1.54 (95% CI, 1.06–2.25)

Spinal surgery All complications

3475 1871 (54.0) 1604 (46.0)

263 NR NR No significant difference in total complication rate between sexes in multivariate analysis; in univariate

analysis, OR, 1.32 (95% CI, 1.02–1.69)

Spinal surgery DVT/PE 27,684 14,221 (51.4)

13,463 (48.6)

283 NR NR Males at increased odds of PE only (p = 0.0119); OR, 1.65 (95% CI, 1.12–2.44)

Spinal fusion Major complications

5887 2782 (47.0) 3092 (53.0)

457 NR NR Statistical difference in major complication rate between sexes NR

Spinal fusion Minor complications

5887 2782 (47.0) 3092 (53.0)

270 NR NR Males at decreased odds of minor complications (p = 0.004); OR, 0.7 (95% CI, 0.5–0.9)

Spinal fusion All complications

5887 2782 (47.0) 3092 (53.0)

608 NR NR Statistical difference in total complication rate between sexes NR

Schwab et al. (2012) [51]

Spinal deformity surgery

Major perioperative complications

953 NR NR 80 18 (32.5*) 54 (67.5*) Statistical difference in major perioperative complication rate

between sexes NR

Shen et al. (2009) [52]

Elective spinal fusion surgery

All complications

122,8475 NR NR 177,392* NR NR Males at decreased odds of all complications (p < 0.001); OR, 0.76 (95% CI, 0.75–0.78)

Singh et al. (2013) [53]

Anterior cervical fusion

Dysphagia 159,590 76,349* (47.8*)

83,241* (52.2*)

4027* 2069* (51.4*) 1958* (48.6*) Males at increased odds of dysphagia (p < 0.001); OR, 1.16 (95% CI, 1.07–1.25)

Wang et al. (2012) [57]

Elective cervical spinal surgery

30-day readmission

58,428 29,438* (50.4*)

28,990 (49.6)

4595 NR NR Males at increased odds of 30-day readmission (p < 0.001); OR, 1.30; (95% CI, 1.22–1.39)

Wang et al. (2012) [57]

30-day readmission

284,640 123,276*

(43.3*)161,364 (56.7)

20,786 NR NR No significant difference in 30-day readmission rate between sexes (p = 0.514); OR, 1.01 (95% CI, 0.98–1.04)

Zheng et al. (2002) [59]

Posterior lumbar spine decompression,

Blood transfusion

112 53 (47.3) 59 (52.7) 70 26 (37.1) 44 (62.9) No significant difference in blood transfusion

fusion, and segmental instrumentation

required between sexes (p = 0.48); OR, 1.57 (95% CI, 0.44–5.59)

*Calculated from information provided in the article; †as reported in the article; ACDF = anterior cervical decompression and fusion; rhBMP-2 = recombinant human bone morphogenetic protein-2; OR = odds ratio; CI = confidence interval; RR = risk ratio; NR = not reported; GI = gastrointestinal; DVT = deep vein thrombosis; VTE = venous thromboembolism; CVA = cerebrovascular accident; PE = pulmonary embolism.

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