Which of the following comorbidities—mild well‑controlled hypertension, mild obstructive sleep apnea, lung nodules with mucous plugging, osteopenia, seronegative rheumatoid arthritis, and BRCA2‑positive status with prior bilateral prophylactic mastectomies and reconstruction—pose potential problems for anterior cervical discectomy and fusion (ACDF) at C4‑C6 in a 62‑year‑old woman with a BMI of 29?

Comorbidities Posing Potential Problems for C4-C6 ACDF

The most clinically significant comorbidities in this patient are osteopenia (affecting fusion success and implant stability), obstructive sleep apnea (increasing airway complication risk), and seronegative rheumatoid arthritis (potentially affecting bone quality and healing), while the remaining conditions pose minimal to no additional surgical risk. 1

High-Risk Comorbidities

Osteopenia

• Osteopenia directly threatens fusion success and hardware stability in multilevel ACDF, as bone density is critical for screw purchase and graft incorporation 1
• Preoperative bone density assessment (DEXA scan) is necessary to evaluate implant stability and fusion success rates, particularly in a 62-year-old female at elevated osteoporosis risk 1
• Reduced bone mineral density increases the risk of cage/graft subsidence (baseline rate 9.4% in normal bone) and hardware failure 2
• Consider bisphosphonate therapy or other bone-strengthening agents preoperatively if DEXA confirms osteoporosis (T-score ≤ -2.5), though this requires coordination with the patient's primary care physician 1

Obstructive Sleep Apnea (OSA)

• OSA significantly increases the risk of postoperative airway complications, particularly excessive neck swelling (11.3% baseline incidence) and respiratory compromise 2
• The anterior cervical approach creates soft tissue edema that can critically narrow an already compromised airway in OSA patients 3, 4
• Mandatory preoperative anesthesia consultation is required to optimize perioperative airway management and determine if the patient requires postoperative ICU monitoring 3
• Ensure the patient brings their CPAP device to the hospital and uses it immediately postoperatively to minimize airway edema and hypoxemia 4
• Extended postoperative observation (potentially 23-hour observation or overnight admission) should be strongly considered even for what might otherwise be an outpatient procedure 5

Seronegative Rheumatoid Arthritis

• RA affects bone quality, healing capacity, and fusion rates, particularly if the patient is on disease-modifying antirheumatic drugs (DMARDs) or biologics 1
• Obtain detailed medication history, specifically regarding methotrexate, TNF-alpha inhibitors, or corticosteroids, as these impact perioperative infection risk and bone healing 6
• Coordinate with rheumatology regarding perioperative medication management—most biologics require temporary discontinuation 1-2 weeks before surgery 6
• RA patients have baseline increased pseudarthrosis risk (baseline 10.0% in general population), which may be higher in this population 2
• Consider using anterior cervical plating, which reduces pseudarthrosis risk from 4.8% to 0.7% in two-level constructs—particularly important given compromised bone healing 1

Moderate-Risk Comorbidities

History of Lung Nodules and Mucous Plugging

• This history raises concern for impaired pulmonary toilet and postoperative atelectasis/pneumonia risk, though it does not contraindicate surgery 3
• Obtain recent pulmonary function tests if not already available and ensure nodules have been appropriately surveilled (no active malignancy) 1
• Preoperative incentive spirometry training and aggressive postoperative pulmonary hygiene protocols are essential 4
• The mucous plugging history suggests chronic airway inflammation that compounds OSA-related airway risks 3

Low-Risk Comorbidities

Mild Well-Controlled Hypertension

• Well-controlled hypertension poses minimal additional surgical risk and does not significantly affect ACDF outcomes 7
• Ensure continuation of antihypertensive medications through the perioperative period (take morning of surgery with sip of water) 5
• Monitor for postoperative hematoma (baseline incidence 5.6%, requiring surgical evacuation in 2.4% of cases), though controlled hypertension does not substantially increase this risk 3

BRCA2-Positive Status with Prior Bilateral Mastectomies and Reconstruction

• This history is essentially irrelevant to ACDF surgical planning and poses no additional perioperative risk 1
• The anterior cervical approach does not involve the chest wall or compromise prior reconstructive surgery 8
• BRCA2 status does not affect bone healing, fusion rates, or surgical complications 7

BMI Considerations

BMI of 29 (Overweight, Not Obese)

• BMI of 29 does not significantly increase complication rates for ACDF, as the threshold for substantially increased risk is typically BMI ≥35 7
• This BMI may slightly increase technical difficulty of the approach but does not contraindicate surgery 1
• Combined with OSA, this BMI warrants heightened vigilance for airway complications, but the BMI itself is not prohibitive 2

Critical Preoperative Optimization Algorithm

1. Obtain DEXA scan immediately—if T-score ≤ -2.5, initiate bone-strengthening therapy and consider delaying surgery 3-6 months for optimization 1
2. Mandatory anesthesia consultation for OSA and airway management planning 3
3. Rheumatology consultation for perioperative DMARD/biologic management 6
4. Pulmonary function tests if not recent, given lung nodule/mucous plugging history 4
5. Plan for extended postoperative monitoring (minimum 23-hour observation) given OSA and airway concerns 5
6. Ensure patient is nicotine-free (though not mentioned in history, this is mandatory for fusion surgery) 6

Surgical Technique Modifications

• Strongly recommend anterior cervical plating for this two-level fusion given osteopenia and RA, as instrumentation reduces pseudarthrosis from 4.8% to 0.7% 1
• Consider allograft over autograft to avoid iliac crest donor site morbidity (20% prolonged pain rate) in a patient with multiple comorbidities, as fusion rates are equivalent (93.4% vs 97%) 1
• Meticulous hemostasis is critical given the 5.6% hematoma rate, which could be catastrophic in an OSA patient with compromised airway 3