Jean-Christophe Leveque

Complication avoidance with pre-operative screening: insights from the Seattle spine team

Complication rates for complex adult lumbar scoliosis surgery are unacceptably high. Standardized preoperative evaluation protocols have been shown to significantly reduce the likelihood of a spectrum of negative outcomes associated with complex adult lumbar scoliosis surgery. To increase patient safety and reduce complication risk, an entire medical and surgical team should work together to care for adult lumbar scoliosis patients. This article describes preoperative patient evaluation strategies with a particular focus on adult lumbar scoliosis surgery involving six or more levels of spinal fusion. Domains considered include recent preoperative evaluation literature, predictive risk modeling, the appropriate management of medical conditions, and the composition and activities of a multidisciplinary conference review team. An evidence-based comprehensive systematic preoperative surgical evaluation process is described.

Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study

Study Design. Observational cohort pilot study. Objective. To determine the impact of a multidisciplinary conference on treatment decisions for lumbar degenerative spine disease. Summary of Background Data. Multidisciplinary decision making improves outcomes in many disciplines. The lack of integrated systems for comprehensive care for spinal disorders has contributed to the inappropriate overutilization of spine surgery in the United States. Methods. We implemented a multidisciplinary conference involving physiatrists, anesthesiologists, pain specialists, neurosurgeons, orthopaedic spine surgeons, physical therapists, and nursing staff. Over 10 months, we presented patients being considered for spinal fusion or who had a complex history of prior spinal surgery. We compared the decision to proceed with surgery and the proposed surgical approach proposed by outside surgeons with the consensus of our multidisciplinary conference. We also assessed comprehensive demographics and comorbidities for the patients and examined outcomes for surgical patients. Results. A total of 137 consecutive patients were reviewed at our multidisciplinary conference during the 10-month period. Of these, 100 patients had been recommended for lumbar spine fusion by an outside surgeon. Consensus opinion of the multidisciplinary conference advocated for nonoperative management in 58 patients (58%) who had been previously recommended for spinal fusion at another institution (&khgr; 2  = 26.6; P < 0.01). Furthermore, the surgical treatment plan was revised as a product of the conference in 28% (16 patients) of the patients who ultimately underwent surgery (&khgr; 2  = 43.6; P < 0.01). We had zero 30-day complications in surgical patients. Conclusion. Isolated surgical decision making may result in suboptimal treatment recommendations. Multidisciplinary conferences can reduce the utilization of lumbar spinal fusion, possibly resulting in more appropriate use of surgical interventions with better candidate selection while providing patients with more diverse nonoperative treatment options. Although long-term patient outcomes remain to be determined, such multidisciplinary care will likely be essential to improving the quality and value of spine care. Level of Evidence: 3

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 patients 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 patients 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.

Preoperative, Intraoperative, and Postoperative Standing Lordosis After Pedicle Subtraction Osteotomy: An Analysis of Radiographic Parameters and Surgical Strategy

STUDY DESIGN Retrospective consecutive case series. OBJECTIVES The objective of this study was to investigate the relationship between intraoperative and postoperative lumbar spine measurements after pedicle subtraction osteotomy (PSO). We analyzed the amount of lordosis lost between the prone intraoperative image and the final upright standing film. The outcome of this analysis should be used in preoperative planning for osteotomy procedures. METHODS Sixteen patients had pre-, intra- and postoperative measurements of lumbar lordosis. Pre- and postoperative measures of pelvic parameters were also determined. Comparisons were made between pre-, intra- and postoperative measures of pelvic parameters, with specific attention to lumbar lordosis correction and the loss of correction with transition to a standing position. RESULTS The average pelvic mismatch between preoperative lumbar lordosis and pelvic incidence was 37 degrees whereas the postoperative mismatch measured 3.2 degrees. All patients had a significant correction of their lumbar lordosis. The lumbar lordosis showed a highly significant loss of 12.5 degrees from the intraoperative prone position to the postoperative standing position, with the average lumbar lordosis intraoperatively (67 degrees) decreasing to a standing lumbar lordosis of 54 degrees (p < .000001). CONCLUSIONS This analysis should aid in preoperative planning for sagittal global alignment correction and can reduce the chance of over- or under-correction in patients having a PSO procedure. Given the narrow postoperative target that is associated with better outcomes for patients, the loss of lumbar lordosis from prone to standing position may be a crucial variable in this planning process.

Risk stratification in deep brain stimulation surgery: Development of an algorithm to predict patient discharge disposition with 91.9% accuracy

Clinical decision making is susceptible to biases and can be improved with the application of predictive models and decision support systems (DSS). The purpose of this study was to develop a predictive risk stratification model and DSS that could accurately predict whether a patient was likely to be of high- or low-acuity discharge disposition (DD) status subsequent to DBS surgery. Data were collected for 135 DBS patients by reviewing medical records. Multivariate logistic regression was applied to develop the predictive algorithm. The two significant predictive models showed good fit and were calibrated by using AUROC curve analysis. The model predicting DD in all patients (n = 135) yielded a predictive accuracy of 91.9% (AUROC = 0.825, p < .001). The model predicting DD in Parkinsons Disease patients (n = 91) yielded a predictive accuracy of 89.0% (AUROC = 0.853, p < .001). Age was a significant predictor of DD across all patients (OR = 1.11, p < .05) and BMI was a significant predictor of DD amongst Parkinsons Disease patients (OR = 1.16, p < .05). It is possible to accurately predict the DD of DBS patients using routinely collected preoperative variables. The predictive algorithms were applied in the form of a model-driven DSS to assist in improving clinical decision making and patient safety.

Preoperative Clinical Evaluation of Adult Lumbar Scoliosis

Complication rates for complex adult lumbar scoliosis surgery are high. Standardized protocols encompassing a comprehensive set of perioperative processes have been shown to significantly reduce the likelihood of a spectrum of complications associated with complex adult lumbar scoliosis surgery. To increase patient safety and reduce risk, an entire team should work together appropriately and effectively to deliver care for the adult lumbar scoliosis patient from their preoperative state through to their recovery.This chapter describes preoperative patient evaluation in adult lumbar scoliosis surgery. Areas of focus include (1) the appropriate management of medical conditions; (2) the role, composition, and activities of a multidisciplinary conference review team; and (3) considerations for the management of osteoporosis. A comprehensive systematic preoperative surgical evaluation process is described. Patient evaluation approaches and processes are scientifically supported by the evidence-based Seattle Spine Team Protocol and by recently published research literature.