Single-Surgeon Versus Dual-Surgeon Strategy in Spinal Tumor Surgery: A Single Institution Experience

Multidisciplinary Surgical Approach Using Augmented Reality Preplanning for Resection of Giant Thoracic Schwannoma With Robotic-Assisted Thoracoscopic Mobilization

BACKGROUND AND IMPORTANCE

In adults, primary spinal cord tumors account for 5% of all primary tumors of the central nervous system, with schwannomas making up about 74% of all nerve sheath tumors. Thoracic schwannomas can pose a threat to neurovasculature, presenting a significant challenge to safe and complete surgical resection. For patients presenting with complex pathologies including tumors, a dual surgeon approach may be used to optimize patient care and improve outcomes.

CLINICAL PRESENTATION

A 73-year-old female previously diagnosed with a nerve sheath tumor of the fourth thoracic vertebra presented with significant thoracic pain and a history of falls. Imaging showed that the tumor had doubled in size ranging from T3 to T5. Augmented reality volumetric rendering was used to clarify anatomic relationships of the mass for perioperative evaluation and decision-making. A dual surgeon approach was used for complete resection. First, a ventrolateral left video-assisted thoracoscopic surgery was performed with robotic assistance followed by a posterior tumor resection and thoracic restabilization. The patient did well postoperatively.

CONCLUSION

Although surgical treatment of large thoracic dumbbell tumors presents a myriad of risks, perioperative evaluation with augmented reality, new robotic surgical techniques, and a dual surgeon approach can be implemented to mitigate these risks.

Does Patient Blood Management Affect Outcomes in Metastatic Spine Tumour Surgery? A Review of Current Concepts

STUDY DESIGN

Narrative review.

OBJECTIVE

The spine is the most common site of metastases, associated with decreased quality of life. Increase in metastatic spine tumour surgery (MSTS) has caused us to focus on the management of blood, as blood loss is a significant morbidity in these patients. However, blood transfusion is also not without its own risks, and hence this led to blood conservation strategies and implementation of a concept of patient blood management (PBM) in clinical practise focusing on these patients.

METHODS

A narrative review was conducted and all studies that were related to blood management in metastatic spine disease as well as PBM surrounding this condition were included.

RESULTS

A total of 64 studies were included in this review. We discussed a new concept of patient blood management in patients undergoing MSTS, with stratification to pre-operative and intra-operative factors, as well as anaesthesia and surgical considerations. The studies show that PBM and reduction in blood transfusion allows for reduced readmission rates, lower risks associated with blood transfusion, and lower morbidity for patients undergoing MSTS.

CONCLUSION

Through this review, we highlight various pre-operative and intra-operative methods in the surgical and anaesthesia domains that can help with PBM. It is an important concept with the significant amount of blood loss expected from MSTS.

LEVEL OF EVIDENCE

Not applicable.

The Surgical Outcomes of Pedicle Subtraction Osteotomy per Different First Assistant: Retrospective Analysis of 312 Cases

INTRODUCTION

Pedicle subtraction osteotomies (PSOs) are complex spinal deformity surgeries that are associated with high complication rates. They are typically done by an experienced spine surgeon with another attending, resident, or physician assistant serving as the first assistant. The purpose of this study was to determine whether selecting a surgical team for single-level PSO based on case difficulty and fusion length could equalize intraoperative and perioperative outcomes among three groups: dual-attending (DA), attending and orthopaedic resident (RS), and attending and physician assistant (PA).

METHODS

This study was a retrospective cohort analysis of 312 patients undergoing single-level thoracic or lumbar PSO from January 2007 to December 2020 by a fellowship-trained orthopaedic spine surgeon. Demographic, intraoperative, and perioperative data within 30 days and 2 years of the index procedure were analyzed.

RESULTS

Patient demographics did not markedly differ between surgical groups. The mean cohort age was 64.5 years with BMI 31.9 kg/m 2 . Patients with the DA approach had a significantly longer surgical time (DA = 412 min vs. resident = 372 min vs. physician assistant = 323 min; P < 0.001). Patients within the DA group experienced a significantly lower rate of infection (DA = 2.1% [3/140] vs. RS = 7.9% [9/114] vs. PA = 1.7% [1/58], P = 0.043), surgical complication rate (DA = 26% [37/140] vs. RS = 41% [47/114] vs. PA = 33% [19/58], P < 0 .001), and readmission rate (DA = 6.4% [9/140] vs. RS = 12.3% [14/114] vs. PA = 19% [11/58] P = 0.030) within 30 days of surgery. No notable differences were observed among groups in 2-year complication, infection, readmission, or revision surgery rates.

CONCLUSIONS

These study results support the DA surgeon approach. Resident involvement, even in less complex cases, can still negatively affect perioperative outcomes. Additional selection criteria development is needed.

Development and External Validation of the Spinal Tumor Surgery Risk Index

BACKGROUND

Patients undergoing surgical procedures for spinal tumors are vulnerable to major adverse events (AEs) and death in the postoperative period. Shared decision making and preoperative optimization of outcomes require accurate risk estimation.

OBJECTIVE

To develop and validate a risk index to predict short-term major AEs after spinal tumor surgery.

METHODS

Prospectively collected data from multiple medical centers affiliated with the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2020 were reviewed. Multiple logistic regression was used to assess sociodemographic, tumor-related, and surgery-related factors in the derivation cohort. The spinal tumor surgery risk index (STSRI) was built based on the resulting scores. The STSRI was internally validated using a subgroup of patients from the American College of Surgeons National Surgical Quality Improvement Program database and externally validated using a cohort from a single tertiary center.

RESULTS

In total, 14 982 operations were reviewed and 4556 (16.5%) major AEs occurred within 30 days after surgery, including 209 (4.5%) deaths. 22 factors were independently associated with major AEs or death and were included in the STSRI. Using the internal and external validation cohorts, the STSRI produced an area under the curve of 0.86 and 0.82, sensitivity of 80.1% and 79.7%, and specificity of 74.3% and 73.7%, respectively. The STSRI, which is freely available, outperformed the modified frailty indices, the American Society of Anesthesiologists classification, and the American College of Surgeons risk calculator.

CONCLUSION

In patients undergoing surgery for spinal tumors, the STSRI showed the highest predictive accuracy for major postoperative AEs and death compared with other current risk predictors.

The "In-Parallel" Technique for Awake, Bilateral Simultaneous Minimally Invasive Transforaminal Lumbar Interbody Fusion and Multilevel Lumbar Decompression

BACKGROUND

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) and MIS lumbar decompression have been successfully undertaken in the absence of general anesthesia in well-selected patients. By leveraging spinal anesthesia, surgeons may safely conduct surgeries on one- or two-level lumbar pathology. However, surgeries on more extensive pathology have not yet been described, because of concerns about the duration of efficacy of spinal anesthetic in the awake patient.

OBJECTIVE

To report the use of a novel awake technique for "in parallel," simultaneous lumbar spinal surgery on three-segment pathology.

METHODS

We describe concurrent performance of a dual microscopic, navigated MIS TLIF and MIS two-level decompression, using a combination of liposomal bupivacaine erector spinae block in conjunction with a spinal anesthetic.

RESULTS

We show that a left-sided, two-level MIS tubular microscopic decompression combined with a concurrent right-sided, transfacet MIS TLIF via a tubular microscopic approach was well tolerated in an 87-year-old patient with multilevel lumbar stenosis with a mobile spondylolisthesis.

CONCLUSION

We provide the first description of a dual-surgeon approach for minimally invasive spine surgery. This "in-parallel" technique-reliant on 2, independent spine surgeons-may aid in the performance of surgeries previously considered too extensive, given the time constraints of regional anesthesia and can be successfully applied to patients who otherwise may not be candidates for general anesthesia.