Using a dedicated spine radiology technologist is associated with reduced fluoroscopy time, radiation dose, and surgical time in pediatric spinal deformity surgery

The effect of surgical time on perioperative complications in adolescent idiopathic scoliosis cases. A propensity score analysis

BACKGROUND

Posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS) can be lengthy and complication-ridden. The aim of this study was to evaluate the effect of surgical time on perioperative complications in this procedure when controlling for confounding variables with propensity score analysis.

METHODS

This was an IRB-approved review of electronic health records from 2010 to 2019 at a single tertiary care children's hospital. Patients undergoing PSIF were grouped into "short" (< 6 h) or "long" (≥ 6 h) surgical time groups. Outcome measures were estimated blood loss (EBL), cell saver transfusions, packed red blood cell (pRBC) transfusions, length of stay (LOS), intraoperative monitoring (IOM) alerts, hematocrit, ICU transfer, neurologic loss, surgical site infection, and 90-day readmissions. We controlled for age, sex, BMI, curve severity, number of segments fused, and surgeon factors.

RESULTS

After propensity score matching there were 113 patients in each group. The short surgical time group had lower EBL (median 715, IQR 550-900 vs median 875, IQR 650-1100 cc; p < 0.001), received less cell saver blood (median 120, IQR 60-168 vs median 160, IQR 97-225 cc; p = 0.001), received less intraoperative pRBCs (median 0, IQR 0-0 vs median 0, IQR 0-320, p = 0.002), had shorter average LOS (4.8 ± 1.7 vs 5.4 ± 2.5 days; p = 0.039), and fewer IOM alerts (4.3% vs 18%, p = 0.003).

CONCLUSIONS

Patients with shorter surgical times had less blood loss, received less transfused blood, had a shorter LOS, and fewer IOM alerts compared to patients with longer surgical times. Surgical times < 6 h may have safety and efficacy advantages over longer times.

LEVEL OF EVIDENCE

III.

Mental Skills for Orthopaedic Surgery

Orthopaedic surgery training focuses primarily on the knowledge base and surgical techniques that comprise the fundamental and physical pillars of performance. It also pays much less attention to the mental pillar of performance than does the training of other specialists such as aviators, elite athletes, musicians, and Special Forces operators. However, mental skills optimize the ability to achieve the ideal state during surgery that includes absolute focus with the right amount of confidence and stress. The path to this state begins before surgery with visualization of the surgical steps and potential complications. On the day of surgery, the use of compartmentalization, performance aspirations, performance breathing, and keeping the team focused facilitates achieving and maintaining the proper mental state. Considering the similarities between surgery and other fields of expertise that do emphasize the mental pillar, including this training in orthopaedic residencies, is likely beneficial.

The machine-vision image guided surgery system reduces fluoroscopy time, ionizing radiation and intraoperative blood loss in posterior spinal fusion for scoliosis

PURPOSE

To determine if the novel 3D Machine-Vision Image Guided Surgery (MvIGS) (FLASH™) system can reduce intraoperative radiation exposure, while improving surgical outcomes when compared to 2D fluoroscopic navigation.

METHODS

Clinical and radiographic records of 128 patients (≤ 18 years of age) who underwent posterior spinal fusion (PSF), utilising either MvIGS or 2D fluoroscopy, for severe idiopathic scoliosis were retrospectively reviewed. Operative time was analysed using the cumulative sum (CUSUM) method to evaluate the learning curve for MvIGS.

RESULTS

Between 2017 and 2021, 64 patients underwent PSF using pedicle screws with 2D fluoroscopy and another 64 with the MvIGS. Age, gender, BMI, and scoliosis aetiology were comparable between the two groups. The CUSUM method estimated that the MvIGS learning curve with respect to operative time was 9 cases. This curve consisted of 2 phases: Phase 1 comprises the first 9 cases and Phase 2 the remaining 55 cases. Compared to 2D fluoroscopy, MvIGS reduced intraoperative fluoroscopy time, radiation exposure, estimated blood loss and length of stay by 53%, 62% 44%, and 21% respectively. Scoliosis curve correction was 4% higher in the MvIGS group, without any increase in operative time.

CONCLUSION

MvIGS for screw insertion in PSF contributed to a significant reduction in intraoperative radiation exposure and fluoroscopy time, as well as blood loss and length of stay. The real-time feedback and ability to visualize the pedicle in 3D with MvIGS enabled greater curve correction without increasing the operative time.

Novel Machine Vision Image Guidance System Significantly Reduces Procedural Time and Radiation Exposure Compared With 2-dimensional Fluoroscopy-based Guidance in Pediatric Deformity Surgery

BACKGROUND

Intraoperative 2-dimensional (2D) fluoroscopy imaging has been commonly adopted for guidance during complex pediatric spinal deformity correction. Despite the benefits, fluoroscopy imaging emits harmful ionizing radiation, which has been well-established to have deleterious effects on the surgeon and operating room staff. This study investigated the difference in intraoperative fluoroscopy time and radiation exposure during pediatric spine surgery between 2D fluoroscopy-based navigation and a novel machine vision navigation system [machine vision image guidance system (MvIGS)].

METHODS

This retrospective chart review was conducted at a pediatric hospital with patients who underwent posterior spinal fusion for spinal deformity correction from 2018 to 2021. Patient allocation to the navigation modality was determined by the date of their surgery and the date of implementation of the MvIGS. Both modalities were the standard of care. Intraoperative radiation exposure was collected from the fluoroscopy system reports.

RESULTS

A total of 1442 pedicle screws were placed in 77 children: 714 using MvIGS and 728 using 2D fluoroscopy. There were no significant differences in the male-to-female ratio, age range, body mass index, distribution of spinal pathologies, number of levels operated on, types of levels operated on, and the number of pedicle screws implanted. Total intraoperative fluoroscopy time was significantly reduced in cases utilizing MvIGS (18.6 ± 6.3 s) compared with 2D fluoroscopy (58.5 ± 19.0 s) ( P < 0.001). This represents a relative reduction of 68%. Intraoperative radiation dose area product and cumulative air kerma were reduced by 66% (0.69 ± 0.62 vs 2.0 ± 2.1 Gycm 2 , P < 0.001) and 66% (3.4 ± 3.2 vs 9.9 ± 10.5 mGy, P < 0.001) respectively. The length of stay displayed a decreasing trend with MVIGS, and the operative time was significantly reduced in MvIGS compared with 2D fluoroscopy for an average of 63.6 minutes (294.5 ± 15.5 vs 358.1 ± 60.6 min, P < 0.001).

CONCLUSION

In pediatric spinal deformity correction surgery, MvIGS was able to significantly reduce intraoperative fluoroscopy time, intraoperative radiation exposure, and total surgical time, compared with traditional fluoroscopy methods. MvIGS reduced the operative time by 63.6 minutes and reduced intraoperative radiation exposure by 66%, which may play an important role in reducing the risks to the surgeon and operating room staff associated with radiation in spinal surgery procedures.

LEVEL OF EVIDENCE

Level III; retrospective comparative study.

A dedicated surgical team for posterior spinal fusion in patients with adolescent idiopathic scoliosis improves OR efficiency

PURPOSE

Standardized care pathways for adolescent idiopathic scoliosis (AIS) patients undergoing PSF improve clinical outcomes. We hypothesized that having dedicated spine personnel would decrease surgical time and improve clinical outcomes.

METHODS

367 patients with AIS had a PSF within a standardized perioperative care pathway. Cases with 1-3 dedicated spine team members (any combination of circulating nurse, surgical technologist, and anesthesiologist) were compared to teams with none. The impact of individual members was also analyzed. Parametric or non-parametric tests were used for each outcome based on the distribution of the data points. These included one-way ANOVA models, Kruskal-Wallis tests, and Fisher's exact tests.

RESULTS

Surgical time and total OR time were significantly decreased with the participation of each additional dedicated team member resulting in 43.86 min less surgical time and 50.8 min less total OR time when three team members were present compared to no team members. If the nurse was a spine member, the surgical time was lower (p = 0.037). If the technologist was a team member, the surgical time and total OR time were lower (p = 0.002 and p = 0.001, respectively). Lastly, if the anesthesiologist was a member of the team, the anesthesia time was lower (p = 0.003). No significant clinical differences were observed.

CONCLUSION

Having dedicated surgical team members decreases surgical and total OR time for AIS patients undergoing PSF, and this OR efficiency improves as the dedicated team is more robust. OR surgical teams did not influence clinical outcomes. Hospitals should strongly consider developing surgical teams to improve OR efficiency of PSF cases.