# Serum Albumin Level as a Predictor of Failure to Rescue in Patients Undergoing Surgery for Spinal Metastases

## TL;DR

Low serum albumin levels before surgery for spinal metastases are linked to higher risk of death after major complications.

## Contribution

This study identifies preoperative serum albumin as a novel predictor of failure to rescue in spinal metastasis surgery.

## Key findings

- Lower preoperative serum albumin levels are independently associated with increased failure to rescue risk.
- Albumin levels above 3.5 g/dL are linked to significantly reduced odds of failure to rescue.
- The study suggests serum albumin could be used for risk stratification in surgical decision-making.

## Abstract

Surgical intervention for spinal metastases can provide meaningful benefits in terms of pain reduction, neurologic preservation, and functional maintenance. However, this population is medically vulnerable, and major postoperative complications can rapidly lead to early mortality. This phenomenon, known as failure to rescue, refers to death following a major complication within 30 days of surgery. In this study, we evaluated whether preoperative serum albumin, a biomarker reflecting nutritional/inflammatory status and physiologic reserve, is associated with failure to rescue risk. We found that even modest hypoalbuminemia was independently associated with this outcome, suggesting that albumin may serve as a useful risk stratification marker to support surgical decision-making and optimize preoperative patient management.

Background/Objectives: Failure to rescue (FTR), defined as the occurrence of a major complication plus death within 30 days, is a key measure of surgical safety. Hypoalbuminemia is a known risk factor for poor outcome in metastatic spinal tumor surgery, yet its association with FTR has not been explored. The purpose of this study is to evaluate serum albumin level as predictor of FTR after surgery for spinal metastases. Methods: A total of 1749 patients with disseminated cancer who underwent oncologic surgery for spinal metastases (identified by CPT codes) and met our inclusion criteria were identified in the ACS-NSQIP database (2018–2023). The primary endpoint was FTR, defined as a major complication plus death occurring within 30 days of surgery. Serum albumin was analyzed both as a continuous and categorical variable (hypoalbuminemia < 3.5 g/dL, normal albumin > 3.5 g/dL). Univariable and multivariable logistic regression was performed, adjusting for demographic and operative variables. Results: The mean preoperative serum albumin level was 3.63 g/dL (standard deviation = 0.642) and the FTR rate was 4% (71 of 1749). After adjusting for potential confounders such as modified Frailty Index 5, ASA class, functional status, emergent case, and reoperation, higher preoperative albumin levels (OR 0.39 [95% CI 0.26–0.61]; p < 0.001) were independently associated with decreased odds of FTR. Conclusions: The findings of this study suggest an association between preoperative serum albumin level and FTR in oncologic surgery for spinal metastases. This highlights the importance of albumin assessment for perioperative prognosis, but the findings require further validation.