• Akash A Shah, Sai K Devana, Changhee Lee, Amador Bugarin, Elizabeth L Lord, Arya N Shamie, Don Y Park, Mihaela van der Schaar, and Nelson F SooHoo.
• Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Electronic address: aashah@mednet.ucla.edu.
• World Neurosurg. 2021 Aug 1; 152: e227e234e227-e234.

BackgroundGiven the significant cost and morbidity of patients undergoing lumbar fusion, accurate preoperative risk-stratification would be of great utility. We aim to develop a machine learning model for prediction of major complications and readmission after lumbar fusion. We also aim to identify the factors most important to performance of each tested model.MethodsWe identified 38,788 adult patients who underwent lumbar fusion at any California hospital between 2015 and 2017. The primary outcome was major perioperative complication or readmission within 30 days. We build logistic regression and advanced machine learning models: XGBoost, AdaBoost, Gradient Boosting, and Random Forest. Discrimination and calibration were assessed using area under the receiver operating characteristic curve and Brier score, respectively.ResultsThere were 4470 major complications (11.5%). The XGBoost algorithm demonstrates the highest discrimination of the machine learning models, outperforming regression. The variables most important to XGBoost performance include angina pectoris, metastatic cancer, teaching hospital status, history of concussion, comorbidity burden, and workers' compensation insurance. Teaching hospital status and concussion history were not found to be important for regression.ConclusionsWe report a machine learning algorithm for prediction of major complications and readmission after lumbar fusion that outperforms logistic regression. Notably, the predictors most important for XGBoost differed from those for regression. The superior performance of XGBoost may be due to the ability of advanced machine learning methods to capture relationships between variables that regression is unable to detect. This tool may identify and address potentially modifiable risk factors, helping risk-stratify patients and decrease complication rates.Copyright © 2021 Elsevier Inc. All rights reserved.

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