Evidence-based recommendations for spine surgery

A systematic multidisciplinary initiative for reducing the risk of complications in adult scoliosis surgery

OBJECTIVE Systematic multidisciplinary approaches to improving quality and safety in complex surgical care have shown promise. Complication rates from complex spine surgery range from 10% to 90% for all surgeries, and the overall mortality rate is 1%-4%. These rates suggest the need for improved perioperative complex spine surgery processes designed to minimize risk and improve quality. METHODS The Group Health Research Institute and Virginia Mason Medical Center implemented a systematic multidisciplinary protocol, the Seattle Spine Team Protocol, in 2010. This protocol involves the following elements: 1) a comprehensive multidisciplinary conference including clinicians from neurosurgery, anesthesia, orthopedics, internal medicine, behavioral health, and nursing, collaboratively deciding on each patient's suitability for surgery; 2) a mandatory patient education course that reviews the risks of surgery, preparation for the surgery, and postoperative care; 3) a dual-attending-surgeon approach involving 1 neurosurgeon and 1 orthopedic spine surgeon; 4) a dedicated specialist complex spine anesthesia team; and 5) rigorous intraoperative monitoring of a patient's blood loss and coagulopathy. The authors identified 71 patients who underwent complex spine surgery involving fusion of 6 or more levels before implementation of the protocol (surgery between 2008 and 2010) and 69 patients who underwent complex spine surgery after the implementation of the protocol (2010 and 2012). All patient demographic variables, including age, sex, body mass index, smoking status, diagnosis of diabetes and/or osteoporosis, previous surgery, and the nature of the spinal deformity, were comprehensively assessed. Also comprehensively assessed were surgical variables, including operative time, number of levels fused, and length of stay. The authors assessed overall complication rates at 30 days and 1 year and detailed deaths, cardiovascular events, infections, instrumentation failures, and CSF leaks. Chi-square and Wilcoxon rank-sum tests were used to assess differences in patient characteristics for patients with a procedure in the preimplementation period from those in the postimplementation period under a Poisson distribution model. RESULTS Patients who underwent surgery after implementation of the Seattle Spine Team Protocol had a statistically significant reduction (relative risk 0.49 [95% CI 0.30-0.78]) in all measured complications, including cardiovascular events, wound infections, other perioperative infections, and implant failures within 30 days after surgery; the analysis was adjusted for age and Charlson comorbidity score. A trend toward fewer deaths in this group was also found. CONCLUSIONS This type of systematic quality improvement strategy can improve quality and patient safety and might be applicable to other complex surgical disciplines. Implementation of these strategies in the treatment of adult spinal deformity will likely lead to better patient outcomes.

Lumbar surgery in work-related chronic low back pain: can a continuum of care enhance outcomes?

BACKGROUND CONTEXT

Systematic reviews of lumbar fusion outcomes in purely workers' compensation (WC) patient populations have indicated mixed results for efficacy. Recent studies on lumbar fusions in the WC setting have reported return-to-work rates of 26% to 36%, reoperation rates of 22% to 27%, and high rates of persistent opioid use 2 years after surgery. Other types of lumbar surgery in WC populations are also acknowledged to have poorer outcomes than in non-WC. The possibility of improving outcomes by employing a biopsychosocial model with a continuum of care, including postoperative functional restoration in this "at risk" population, has been suggested as a possible solution.

PURPOSE

To compare objective socioeconomic and patient-reported outcomes for WC patients with different lumbar surgeries followed by functional restoration, relative to matched comparison patients without surgery.

STUDY DESIGN/SETTING

A prospective cohort study of chronic disabling occupational lumbar disorder (CDOLD) patients with WC claims treated in an interdisciplinary functional restoration program.

PATIENT SAMPLE

A consecutive cohort of 564 patients with prerehabilitation surgery completed a functional restoration and was divided into groups based on surgery type: lumbar fusion (F group, N=331) and nonfusion lumbar spine surgery (NF group, N=233). An unoperated comparison group was matched for length of disability (U group, N=349).

OUTCOME MEASURES

Validated patient-reported measures of pain, disability, and depression were administered pre- and postrehabilitation. Socioeconomic outcomes were collected via a structured 1-year "after" interview.

METHODS

All patients completed an intensive, medically supervised functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach. The writing of this article was supported in part by National Institutes of Health Grant 1K05-MH-71892; no conflicts of interest are noted among the authors.

RESULTS

The F group had a longer length of disability compared with the NF and U groups (M=31.6, 21.7, and 25.9 months, respectively, p<.001). There were relatively few statistically significant differences for any socioeconomically relevant outcome among groups, with virtually identical postrehabilitation return-to-work (F=81%, NF=84%, U=85%, p=.409). The groups differed significantly after surgery on diagnosis of major depressive disorder and opioid dependence disorder as well as patient-reported depressive symptoms and pain intensity prerehabilitation. However, no significant differences in patient-reported outcomes were found postrehabilitation. Prerehabilitation opioid dependence disorder significantly predicted lower rates of work return and work retention as well as higher rates of treatment-seeking behavior. Higher levels of prerehabilitation perceived disability and depressive symptoms were significant risk factors for poorer work return and retention outcomes.

CONCLUSIONS

Lumbar surgery in the WC system (particularly lumbar fusion) have the potential achieve positive outcomes that are comparable to CDOLD patients treated nonoperatively. This study suggests that surgeons have the opportunity to improve lumbar surgery outcomes in the WC system, even for complex fusion CDOLD patients with multiple prior operations, if they control postoperative opioid dependence and prevent an excessive length of disability. Through early referral of patients (who fail to respond to usual postoperative care) to interdisciplinary rehabilitation, the surgeon determining this continuum of care may accelerate recovery and achieve socioeconomic outcomes of relevance to the patient and WC jurisdiction through the combination of surgery and postoperative rehabilitation.

Comparative effectiveness research in spine surgery

Degenerative spine disorders are a significant cause of patient morbidity and are a prominent factor in healthcare costs in many countries. Pressure for healthcare cost control and the desire for improved outcomes have led to an expanding emphasis on evidence-based medicine methodologies in spine research. Determination of the optimal treatment paradigm for many common degenerative spinal disorders has proven difficult and comparative effectiveness research is increasingly being employed to examine these clinical dilemmas. The Swedish Spine Registry and the Registry of the Scoliosis Research Society are two of the long-standing databases compiling data for spine patients. Spine surgery professional organizations have recently taken a prominent role in assembling procedural- and diagnosis-based registries, specifically addressing therapeutic outcomes for spine patients. As healthcare systems continue to evolve, comparative effectiveness research driven by spine registries may better elucidate the appropriate clinical choices for patients with these challenging illnesses.