Comments on “Impact of Immunosuppression Type on 30-Day Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion: A Retrospective National Cohort Study of 66,162 Patients”

Abstract

We read with interest the study by Phadke et al examining the association between immunosuppression type and 30-day outcomes following anterior cervical discectomy and fusion (ACDF). 1 Distinguishing corticosteroid exposure from other immunosuppressive therapies is clinically important; however, two issues warrant clarification before the findings are translated into perioperative management recommendations. First, the propensity score–matched mortality result is reported inconsistently. In the Results and Table 2 of the original article, 30-day mortality did not reach statistical significance after propensity score matching (aOR 1.50, 95% CI 0.79–2.86; p = .22). 1 In contrast, the Abstract, Figure 1 legend of the original article, and Table 3 of the original article note report a statistically significant matched mortality estimate of aOR 2.10 (95% CI 1.09–4.03; p = .03). 1 The distinction is clinically consequential rather than merely numerical: one estimate does not demonstrate a statistically significant mortality association, whereas the other suggests an approximately twofold increase. Clarification of which propensity-matched estimate is correct is therefore essential, particularly because mortality contributes to the study’s interpretation of corticosteroid-associated postoperative risk. Second, the proposed management implication appears stronger than the comparative evidence permits. The authors appropriately acknowledge that the NSQIP corticosteroid variable does not capture dose, duration, or indication and cannot reliably distinguish chronic high-dose immunosuppression from brief corticosteroid exposure; they also identify confounding by indication as an important residual concern. 1 In the medication-class analysis, biologic DMARD (n = 71) and synthetic DMARD (n = 129) groups had less than 10% observed power, and the authors explicitly caution that their null findings should not be interpreted as evidence of safety. 1 Nevertheless, the conclusion suggests that perioperative risk modification should focus on corticosteroid burden rather than blanket cessation of biologic or synthetic DMARD therapy. 1 The guideline cited in the study addresses elective total hip and knee arthroplasty rather than cervical spine surgery, 2 while the cited systematic review evaluates orthopaedic procedures more broadly rather than ACDF specifically. 3 The present data establish an association between recorded corticosteroid exposure and adverse outcomes