An aid to the explanation of surgical risks and complications: the International Spinal Surgery Information Sheet

Discourse-based psychological intervention alleviates perioperative anxiety in patients with adolescent idiopathic scoliosis in China: a retrospective propensity score matching analysis

PURPOSE

To evaluate the effectiveness of a discourse-based psychological intervention on perioperative anxiety, pain and life satisfaction of patients with AIS.

METHODS

Between April 2018 and February 2021, 116 consecutive patients with AIS undergoing corrective surgery were enrolled in this study, including 51 with personalized psychological intervention (intervention group, IG) and 65 without (control group, CG). After propensity score matching (PSM), patient characteristics, perioperative scores of anxiety and life satisfaction, measured by values of Generalized Anxiety Disorder 7-item Scale (GAD-7) and Life Satisfaction Index Z scale (LSIZ), were recorded. Mixed linear models were used to estimate the influence of intervention group and time of measurement, as well as their interactions, in anxiety and life satisfaction. Data on post-surgical pain in both groups was also collected and analyzed.

RESULTS

After PSM, a total of 90 patients (IG, n = 45; CG, n = 45) were enrolled in this study, and the 2 groups were comparable in patients' demographic and baseline characteristics. There were no pre-intervention between-group differences in the degree of anxiety (IG: 3.98 ± 3.27 vs. CG: 3.93 ± 3.20, p = .948, Cohen's d = 0.015), and life satisfaction (IG: 6.56 ± 1.70 vs. CG: 6.67 ± 2.09, p = .783, Cohen's d = -0.058). After surgery, participants in both IG and CG showed improved the levels of anxiety (GAD-7: IG 2.18 ± 1.21; CG 2.87 ± 2.00) and life satisfaction (LSIZ: IG 9.84 ± 2.09; CG 9.02 ± 2.15). A stratified analysis of patients with generalized anxiety disorder showed improved anxiety (GAD-7: IG 3.50 ± 1.22 vs. CG 6.80 ± 2.05, p = .017, Cohen's d = -1.956) and lower pain level (VAS: IG 4.50 ± 1.76 vs. CG 7.00 ± 1.00, p = .017, Cohen's d = -1.747) in the IG than the CG after surgery.

CONCLUSIONS

Discourse-based psychological intervention before surgery can improve perioperative anxiety and life satisfaction, and postoperative painful condition, especially for patients with high-leveled pre-surgical anxiety.

What are parents willing to accept? A prospective study of risk tolerance in AIS surgery

INTRODUCTION

Surgical treatment of Adolescent Idiopathic Scoliosis (AIS) involves healthy individuals with spinal deformity. Parents are responsible for surgical consent on behalf of their children, a burden which causes trepidation and concern. Therefore, explanation of operative risk is a critical component of informed consent and parent decision-making. We set out to quantify parental risk aversion (RA).

METHODS

RA questionnaires were administered preoperatively to parents of 58 AIS patients undergoing spinal fusion (SF). RA is the likelihood of a parent to consent to their child's SF (1- least likely, 10- most) with increasing allotments of data about potential complications at each stage (S1-complication named, S2-explained, S3-incidence given, S4-all information). A statistically significant mean difference in answers for each stage was assessed using paired sample t test or Wilcoxon rank t test. Normality was assessed by performing Shapiro-Wilk test.

RESULTS

AIS patients (age 14.2 years, 85% female, major curve 61°) were included. Mean scores for each of the stages were 4.4 ± 3.1, 4.9 ± 3.1, 6.5 ± 3.0, 6.6 ± 3.0, respectively. Highest and lowest RA were reported for death and infection, respectively. The greatest increase in likelihood to proceed with surgery was seen after education on malposition of implants and on death, 2.6 and 2.5, respectively (p < 0.001). The lowest increase in likelihood to proceed with surgery was seen after education on infection, 1.5 (p < 0.001). For all complications, there was an increase in parent willingness to proceed after providing descriptions and occurrence rate with a mean increase from S1 to S4 of 2.1 (95% CI 1.4-2.4), p < 0.001.

CONCLUSION

As more detailed information was made available regarding potential complications with SF for AIS, parental RA toward surgery decreased and their willingness to proceed with surgery for their child improved.

Patient Education in Neurosurgery: Part 2 of a Systematic Review

BACKGROUND

Increasing focus has been placed on patient education to optimize care. In the second part of a 2-part systematic review, we characterize the scope of interventions specifically created to improve neurosurgery patient education, assess the effectiveness of these interventions, and extract features of existing interventions that may be incorporated into future patient education interventions. Our findings may help promote the creation of effective, patient-centered educational interventions.

METHODS

A 2-part systematic review was conducted using the PubMed, Embase, and Scopus databases. Titles and abstracts were read and selected for full text review. Studies meeting prespecified inclusion criteria were reviewed in full and analyzed for study design, aim, population, interventions, and outcomes.

RESULTS

Of 1617 resultant articles, 33 were included. Print materials, electronic materials, models, and interventions using multiple modalities improved patient knowledge, decreased anxiety, and increased satisfaction. Electronic materials were preferred. Interventions using multiple modalities engaging multiple sensory systems were reported most beneficial. Video was rated the most effective medium for reinforcing spoken conversation between neurosurgeons and patients. Three-dimensional models decreased the time required for preoperative patient conversation but could be perceived as emotionally confronting. Virtual reality was preferred to patient models.

CONCLUSIONS

Electronic interventions using multiple modalities in concert with each other may be most effective. Interventions should incorporate baseline knowledge and health literacy and address patient concerns and needs in a manner that is valid cross-contextually, uses clear communication, and is continuous. These interventions will improve the patient-friendliness of discussions with patients.

Cervical endoscopic spinal surgery: A review of the current literature

Cervical endoscopic spinal surgery (CESS) is now regularly performed in some centres in the Far East, yet rarely in Europe and the United States. This review describes the application of CESS through anterior and posterior approaches with analysis of the available evidence supporting current techniques. An electronic literature search identified 52 papers and proceedings' abstracts of which 25 (16 anterior approach and 9 posterior approach) provided comparable clinical outcomes. The results revealed a good or excellent outcome from CESS in 91% (range 74-100%) with a complication rate of 5%. In a local cohort study, patients had 72% less neck pain (visual analogue scale rating) and 81% less arm pain at 6 months when CESS was used as an isolated procedure, and 74% less neck pain and 83% less arm pain when coupled with disc replacement or fusion at an adjacent level.

Informed consent in spinal surgery

Informed consent is a very important part of surgical treatment. In this paper, we report a number of legal judgements in spinal surgery where there was no criticism of the surgical procedure itself. The fault that was identified was a failure to inform the patient of alternatives to, and material risks of, surgery, or overemphasizing the benefits of surgery. In one case, there was a promise that a specific surgeon was to perform the operation, which did not ensue. All of the faults in these cases were faults purely of the consenting process. In many cases, the surgeon claimed to have explained certain risks to the patient but was unable to provide proof of doing so. We propose a checklist that, if followed, would ensure that the surgeon would take their patients through the relevant matters but also, crucially, would act as strong evidence in any future court proceedings that the appropriate discussions had taken place. Although this article focuses on spinal surgery, the principles and messages are applicable to the whole of orthopaedic surgery.

Cite this article: Bone Joint J 2019;101-B:355–360.

Multi-level spine endoscopy: A review of available evidence and case report

In the last ten years, there has been an exponential increase in endoscopic spinal surgery practice.

With improvements in equipment quality and the availability of high definition camera systems, cervical endoscopic disc resection is now a viable alternative to anterior cervical decompression and fusion (ACDF) or disc arthroplasty for the treatment of disc prolapse and low grade stenosis.

Based on the current literature, there is now strong evidence to support the use of transforaminal endoscopic approaches for the treatment of thoracic disc prolapse.

There is now level I evidence to show that outcomes following transforaminal endoscopic discectomy (TED) are at least equivalent to those after open microdiscectomy, with an expected shorter operating time, lesser requirement for analgesia, reduced duration of post-operative disability, more rapid rehabilitation and lower costs of care. However, it should be recognised that there is a significant learning curve for TED.

New endoscopic techniques with interlaminar approaches allow the decompression of central and lateral recess stenosis. Future developments will facilitate vision and access to the spine with 3D imaging and robotics at the forefront.

We present a case report of whole spine endoscopic decompression to illustrate the potential of endoscopic surgery at all spinal levels.

Cite this article: EFORT Open Rev 2017;2:317-323. DOI: 10.1302/2058-5241.2.160087

The Knowledge Test Feedback Intervention (KTFI) increases knowledge level of spinal stenosis patients before operation-A randomized controlled follow-up trial

OBJECTIVE

To assess the impact of a preoperative educational intervention on the knowledge level of patients with spinal stenosis.

METHODS

One hundred spinal stenosis patients were randomized into a preoperative educational intervention group (IG, n=50) or a control group (CG, n=50). All the patients received routine preoperative education. In addition, the IG went through an empowering telephone discourse based on a knowledge test performed before admission to hospital. Data on patients' knowledge level were collected at baseline (after the treatment decision), admission to hospital, discharge from hospital and at 3 and 6 months follow-up.

RESULTS

At baseline, there was no difference in the knowledge level of the study groups. At admission, the knowledge level was significantly higher in five of six dimension of empowering knowledge in the IG compared to the CG. During follow-up, the knowledge level within the study groups remained stable.

CONCLUSION

A preoperative KTFI significantly increased the patients' knowledge level in most dimensions of empowering knowledge.

PRACTICE IMPLICATION

KTFI is an effective method of preoperative education in patients with spinal stenosis.

The ‘three-legged stool’

Many hospitals do not have a structured process of consent, the attainment of which can often be rather ‘last-minute’ and somewhat chaotic. This is a surprising state of affairs as spinal surgery is a high-risk surgical specialty with potential for expensive litigation claims. More recently, the Montgomery ruling by the United Kingdom Supreme Court has placed the subject of informed consent into the spotlight.

There is a paucity of practical guidance on how a consent process can be achieved in a busy clinical setting. The British Association of Spinal Surgeons (BASS) has convened a working party to address this need. To our knowledge this is the first example of a national professional body, representing a single surgical specialty, taking such a fundamental initiative.

In a hard-pressed clinical environment, the ability to achieve admission reliably on the day of surgery, in patients at ease with their situation and with little likelihood of late cancellation, will be of great benefit. It will reduce litigation and improve the patient experience.

Cite this article: Bone Joint J 2016;98-B:1427–30.

Adult Spinal Deformity Patients Recall Fewer Than 50% of the Risks Discussed in the Informed Consent Process Preoperatively and the Recall Rate Worsens Significantly in the Postoperative Period

STUDY DESIGN

Recall of the informed consent process in patients undergoing adult spinal deformity surgery and their family members was investigated prospectively.

OBJECTIVE

To quantify the percentage recall of the most common complications discussed during the informed consent process in adult spinal deformity surgery, assess for differences between patients and family members, and correlate with mental status.

SUMMARY OF BACKGROUND DATA

Given high rates of complications in adult spinal deformity surgery, it is critical to shared decision making that patients are adequately informed about risks and are able to recall preoperative discussion of possible complications to mitigate medical legal risk.

METHODS

Patients undergoing adult spinal deformity surgery underwent an augmented informed consent process involving both verbal and video explanations. Recall of the 11 most common complications was scored. Mental status was assessed with the mini-mental status examination-brief version. Patients subjectively scored the informed consent process and video. After surgery, the recall test and mini-mental status examination-brief version were readministered at 5 additional time points: hospital discharge, 6 to 8 weeks, 3 months, 6 months, and 1 year postoperatively. Family members were assessed at the first 3 time points for comparison.

RESULTS

Fifty-six patients enrolled. Despite ranking the consent process as important (median overall score: 10/10; video score: 9/10), median patient recall was only 45% immediately after discussion and video re-enforcement and subsequently declined to 18% at 6 to 8 weeks and 1 year postoperatively. Median family recall trended higher at 55% immediately and 36% at 6 to 8 weeks postoperatively. The perception of the severity of complications significantly differs between patient and surgeon. Mental status scores showed a transient, significant decrease from preoperation to discharge but were significantly higher at 1 year.

CONCLUSION

Despite being well-informed in an optimized informed consent process, patients cannot recall most surgical risks discussed and recall declines over time. Significant progress remains to improve informed consent retention.

LEVEL OF EVIDENCE

3.

Transforaminal endoscopic spinal surgery: the future 'gold standard' for discectomy? - A review

BACKGROUND

Lumbar disc prolapse is common and the primary method of care in most centres is still open discectomy facilitated by microscope or loupe magnification and illumination. Hospitalisation may be less than 24 h, but post-operative pain usually requires an overnight stay. This review describes transforaminal endoscopic spinal surgery (TESS) using HD-video technology, that is generally performed as a day case procedure under sedation or light general anaesthesia, and collates the evidence comparing the technique to microdiscectomy.

METHODS

The method of TESS is described and an electronic literature search performed to identify papers reporting clinical outcomes. International data were translated where necessary and proceedings' abstracts included. In addition, papers held by the authors and colleagues in personal libraries were carefully cross-referenced to the obtained database.

RESULTS

Analysis of the data supports the use of a transforaminal endoscopic approach to the lumbar intervertebral disc and suggests that outcomes following surgery are at least equivalent to those following microdiscectomy. Significant cost-savings in terms of in-patient stay may be generated. In addition, there is also some evidence supporting endoscopic surgery for relief of foraminal stenosis.

CONCLUSION

Based on current evidence there are good arguments supporting a more wide-spread adoption of transforaminal endoscopic surgery for the treatment of lumbar disc prolapse with or without foraminal stenosis.