Nowhere to Heal: Investigating Disparities in Post-operative Spine Care for the Homeless

Introduction: Homelessness (HL) can have enormous impacts on surgical outcomes. Transportation difficulties, access to hygiene supplies, poor nutrition, and more make recovery from surgery incredibly difficult. Regarding spine surgery, there is a 1-4% risk of infection, and with instrumentation, this risk may jump up to 12%.

Methods: We conducted a retrospective review of all spinal deformity surgeries at our tertiary care center from 2016-2023 (n=277) to study how the barriers to care associated with HL impact infection rates and follow up times for spinal deformity surgery. We collected patients who had an ICD-10 code diagnosis of HL prior to surgery and compared their instances of infection and follow-up times to those who had no mention of HL in their medical records pre-operatively. A Chi-Squared test was performed to determine differences in wound infection/breakdown and a one-way ANOVA was performed to compare follow-up times.

Results: Eight of 277 of patients were experiencing HL prior to surgery. HL significantly increased the risk of sepsis (HL n=1, 12.5%; non-HL n=2, 0.7%, p=0.001), although it did not significantly increase the risk of wound infection or breakdown post-operatively (HL n = 1, 12.5%, non-HL n = 10, 3.7%; p = 0.211). HL did not increase the risk of pneumonia (p=0.67) nor urinary tract infections (p=0.64). HL also played a role in follow-up times. People experiencing HL were lost to follow-up sooner than those who were housed (HL mean 150 days ± 124; non-HL mean = 584 days ± 468; p = 0.06).

Conclusion : Caring for patients experiencing homelessness adds several complications, including lack of a place to recover and inconsistent transportation for follow-up care. Our results demonstrate that individuals experiencing homelessness may be at a higher risk for sepsis and loss to follow-up, despite having no significant increase in risk of wound infection.