‘After-hours’ non-elective spine surgery is associated with increased perioperative adverse events in a quaternary center

  • Raphaële Charest-MorinEmail author
  • Alana M. Flexman
  • Michael Bond
  • Tamir Ailon
  • Nicolas Dea
  • Marcel Dvorak
  • Brian Kwon
  • Scott Paquette
  • Charles G. Fisher
  • John Street
Original Article



‘After-hours’ non-elective spinal surgeries are frequently necessary, and often performed under sub-optimal conditions. This study aimed (1) to compare the characteristics of patients undergoing non-elective spine surgery ‘After-hours’ as compared to ‘In-hours’; and (2) to compare the perioperative adverse events (AEs) between those undergoing non-elective spine surgery ‘after-hours’ as compared to ‘in-hours’.


In this retrospective study of a prospective non-elective spine surgery cohort performed in a quaternary spine center, surgery was defined as ‘in-hours’ if performed between 0700 and 1600 h from Monday to Friday or ‘after-hours’ if more than 50% of the operative time occurred between 1601 and 0659 h, or if performed over the weekend. The association of ‘after-hours’ surgery with AEs, surgical duration, intraoperative estimated blood loss (IOBL), length of stay and in-hospital mortality was analyzed using stepwise multivariate logistic regression.


A total of 1440 patients who underwent non-elective spinal surgery between 2009 and 2013 were included in this study. A total of 664 (46%) procedures were performed ‘after-hours’. Surgical duration and IOBL were similar. About 70% of the patients operated ‘after-hours’ experienced at least one AE compared to 64% for the ‘in-hours’ group (p = 0.016). ‘After-hours’ surgery remained an independent predictor of AEs on multivariate analysis [adjusted OR 1.30, 95% confidence interval (CI) 1.02–1.66, p = 0.034]. In-hospital mortality increased twofold in patients operated ‘after-hours’ (4.4% vs. 2.1%, p = 0.013). This association lost significance on multivariate analysis (adjusted OR 1.99, 95% CI 0.98–4.06, p = 0.056).


Non-elective spine surgery performed ‘after-hours’ is independently associated with increased risk of perioperative adverse events, length of stay and possibly, mortality. Research is needed to determine the specific factors contributing to poorer outcomes with ‘after-hours’ surgery and strategies to minimize this risk.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.


‘After-hours’ Out of hours Adverse event Complication In-hospital mortality Length of stay Surgical duration Intraoperative blood loss Spine 



We are grateful to the local clinical research personnel, support staff and medical students for their active participation: Juliet Batke, Leilani Reichl, Allan Aludino Angela Tsang, Lise Bélanger, Leanna Ritchie, Eryck Moskven and Samuel Vijayan.

Compliance with ethical standards

Conflict of interest

None of the authors has relevant conflicts of interest related to this work. Dr. Fisher and Dr. Dvorak have received royalties from Medtronic. Dr. Fisher and Dvorak have received consulting fees from Medtronic. Dr. Fisher has received consulting fees from Nuvasive. Dr. Street and Dr. Fisher received an OREF Grant paid to the institution and AOSPINE provides a fellowship support paid to the institution.

Supplementary material

586_2018_5848_MOESM1_ESM.pptx (149 kb)
Supplementary material 1 (PPTX 148 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Raphaële Charest-Morin
    • 1
    Email author
  • Alana M. Flexman
    • 2
  • Michael Bond
    • 3
  • Tamir Ailon
    • 1
  • Nicolas Dea
    • 1
  • Marcel Dvorak
    • 1
  • Brian Kwon
    • 1
  • Scott Paquette
    • 1
  • Charles G. Fisher
    • 1
  • John Street
    • 1
  1. 1.Department of Orthopedic Surgery, Blusson Spinal Cord CentreUniversity of British ColumbiaVancouverCanada
  2. 2.Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General HospitalUniversity of British ColumbiaVancouverCanada
  3. 3.Department of Orthopaedic SurgeryUniversity of British ColumbiaVancouverCanada

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