The Effect of Two Attending Surgeons on Patients With Large-Curve Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion

Two AIS Cases, 2 Surgeons, 1 Operating Room, 1 Day: Faster and Safer Than 1 Case in a Day

BACKGROUND

To lessen surgical times for patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal instrumentation and fusion (PSIF), our department developed a quality improvement initiative where 2 AIS cases were completed in 1 day by the same 2 surgeons operating together in 1 operating room (OR). We describe the results of this initiative, comparing operative times and outcomes to cases of these surgeons operating individually.

METHODS

From 2017 to 2023, patients aged 10 to 18 years with AIS undergoing PSIF were prospectively enrolled for "Two Spine Tuesday." Patients were matched by age, sex, curve severity, and number of levels fused to historical AIS controls. Outcomes included surgery time, total OR time, estimated blood loss (EBL), volume of cell saver transfused, allogenic blood transfusion, length of stay, 90-day readmissions, Clavien-Dindo-Sink Complication Classification System complication rates, and percentage who achieved the minimal clinically important difference (MCID) for SRS-22.

RESULTS

Fifty-five patients composing the 2-spine group (group 2) were compared with 55 historical sex-matched and age-matched controls (group 1). Major coronal curve and average number of levels fused were similar between groups. Overall surgery time (203 vs. 296 min, P <0.001), total OR time ( P <0.001), and EBL (400 vs. 550 mL, P <0.001) were lower for group 2. Group 2 had fewer complications [n=17 (31%) vs. n=28 (51%), P =0.03].

CONCLUSIONS

Performing 2 AIS cases in 1 OR by 2 surgeons the same day resulted in shorter surgery times, less total time in the operating room, lower complication rates, and less blood loss compared with single-surgeon matched controls.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Risk factors for allogeneic red blood cell transfusion in adult spinal deformity surgery

STUDY DESIGN

Retrospective study.

PURPOSE

To investigate the risk factors for allogeneic red blood cell (RBC) transfusion in adult spinal deformity (ASD) surgery.

OVERVIEW OF LITERATURE

Studies have not thoroughly explored the roles of intraoperative hypothermia, autologous blood donation, and hemostatic agent administration, which would provide a better understanding of the risk for perioperative RBC transfusion in ASD surgery.

METHODS

The medical records of 151 patients with ASD who underwent correction surgery between 2012 and 2021 were retrospectively reviewed. Estimated blood loss and perioperative allogeneic transfusion were examined. Patients were categorized into two groups based on whether they received perioperative allogeneic blood transfusion. Logistic regression analysis was employed to investigate the effect of age, sex, blood type, body mass index, American Society of Anesthesiologists' physical status, preoperative hemoglobin level, autologous blood donation, global spine alignment parameters, preoperative use of anticoagulants or antiplatelet medicine and nonsteroidal anti-inflammatory drugs, number of instrumented fusion levels, total operative duration, three-column osteotomy, lateral interbody fusion, pelvic fixation, intraoperative hypothermia, use of gelatin-thrombin based hemostatic agents, and intraoperative tranexamic acid (TXA) with simultaneous exposure by two attending surgeons.

RESULTS

The estimated blood loss was 994.2±754.5 mL, and 71 patients (47.0%) received allogeneic blood transfusion. In the logistic regression analysis, the absence of intraoperative TXA use and simultaneous exposure (odds ratio [OR], 26.3; 95% confidence interval [CI], 7.6-90.9; p<0.001), lack of autologous blood donation (OR, 21.2; 95% CI, 4.4-100.0; p<0.001), and prolonged operative duration (OR, 1.6; 95% CI, 1.3-1.9; p<0.001) were significant independent factors for perioperative allogeneic blood transfusion in ASD surgery.

CONCLUSIONS

Autologous blood storage, intraoperative TXA administration, and simultaneous exposure should be considered to minimize perioperative allogeneic blood transfusion in ASD surgery, particularly in patients with anticipated lengthy surgeries.

Dual Versus Single Attending Surgeon Performance of Spinal Deformity Surgery? A Meta-Analysis

BACKGROUND

The inclusion of 2 surgeons in spinal deformity surgery is considered beneficial by some. In fact, select studies indicate advantages such as reduced operation time and blood loss. Another observed decreased patient morbidity with a dual-surgeon approach, attributed to shorter operative times and reduced intraoperative blood losses. Therefore, this meta-analysis will assess the benefits of a having 2 surgeons compared to 1 surgeon during spine surgeries.

METHODS

PubMed, Cochrane, and Google Scholar (page 1-20) were searched till January 2024. The clinical outcomes evaluated were the incidence of adverse events, the rate of transfusion, reoperation, and surgery-related parameters such as operative room time, length of stay (LOS), and estimated blood loss.

RESULTS

Thirteen studies were included. A greater rate of complications was seen in patients operated upon by 1 surgeon (odds ratio = 0.50; 95% confidence intervals [CI]: 0.25-0.99, P = 0.05). Furthermore, operative room time (mean differences = -82.73; 95% CI: -111.42 to -54.03, P < 0.001) and LOS (mean differences = -0.91; 95% CI: -1.12 to -0.71, P < 0.001) were reduced in the dual surgeon scenario. No statistically significant difference was shown in the remaining analyzed outcomes.

CONCLUSIONS

The presence of 2 surgeons in the odds ratiowas shown to reduce complications, operative room time, and LOS. More cost-effectiveness studies are needed in order to substantiate the financial advantages associated with the dual-surgeon approach.

Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders

Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.

Utilizing two surgeons for neuromuscular scoliosis suggests improved operative efficiency

PURPOSE

Neuromuscular scoliosis (NMS) patients tend to have significant comorbidities with complex medical and surgical histories. When undergoing posterior spinal fusion (PSF), NMS risks can be much higher than the idiopathic population. This study aimed to identify the impact of two experienced pediatric cosurgeons (CS) compared to a single spine surgeon (SS) on the intra- and postoperative results of NMS PSF.

METHODS

A database of NMS patients who had undergone PSF 2016-2021 identified 53 patients, of which 32 were CS, while 21 were SS. Patients' sex, age, weight, diagnosis, curve severity, fusion performed, estimated blood loss (EBL), transfusion rates, hemoglobin, anesthesia and surgical times, length of stay, and complications were collected.

RESULTS

Patient demographics were similar between groups. Curves were more severe in the CS group (p = 0.013). Intraoperatively, CS patients underwent larger corrections (p = 0.089) but in significantly shorter anesthetic (p = 0.0018) and operative (p = 0.0025) times. Blood loss and transfusions were similar. Postoperatively, intensive-care unit (ICU) admission and length of stay (LOS) were similar, but SS had higher rates of both unplanned ICU admissions (p = 0.36) and 30 day readmissions (p = 0.053). Complications overall were similar between the groups both within 30 days (p = 0.40) and in the short-term period (31-90 days, p = 0.76), though the CS cohort had less Grade 2 immediate postoperative pulmonary complications (p = 0.16).

CONCLUSION

Utilizing CS for NMS PSF has been found to reduce operative times. Downstream, additional potential impacts trended toward fewer unplanned ICU admissions, less-frequent postoperative pulmonary complications, and reduced 30-day readmission rates.

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

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The objective of this study is to compare the outcomes of spinal tumor surgery between dual-surgeon and single-surgeon approach.

SUMMARY OF BACKGROUND DATA

Perioperative adverse outcomes may be improved with 2 attending surgeons in spinal deformity cases. It is unclear if this advantage may be seen in spinal oncology operations.

METHODS

A retrospective chart review identified 24 patients who underwent spinal tumor surgery by two attending surgeons between January 1, 2016, and April 30, 2020 at a single tertiary care institution. 1:1 matching was then performed to identify 24 patients who underwent spinal tumor operations of similar complexity by a single attending surgeon. Postoperative outcomes were collected.

RESULTS

Cases in the dual-surgeon group had significantly lower total operative time (601 vs. 683 minutes), reduced estimated blood loss (956 vs. 1780 ml), and were less likely to have an intraoperative blood transfusion (41.7% vs. 75.0%). The incidence of cerebrospinal fluid leak and wound infection did not significantly differ between groups, nor were there differences in total length of hospital stay, discharge disposition, 6-month emergency room visit, readmission, and reoperation rates.

CONCLUSION

Dual-surgeon strategy in spinal tumors surgery may lead to decreased operative time and estimated blood loss. These benefits may have clinical and cost implications, but should be weighed against the impact of resident and fellow training.

LEVEL OF EVIDENCE

Level III.

Resection of congenital hemivertebra in pediatric scoliosis: the experience of a two-specialty surgical team

OBJECTIVE

Institutions investigating value and quality emphasize utilization of two attending surgeons with different areas of technical expertise to treat complex surgical cases and to minimize complications. Here, the authors chronicle the 12-year experience of using a two-attending surgeon, two-specialty model to perform hemivertebra resection in the pediatric population.

METHODS

Retrospective cohort data from 2008 to 2019 were obtained from the NewYork-Presbyterian Morgan Stanley Children's Hospital operative database. This database included all consecutive pediatric patients < 21 years old who underwent hemivertebra resection performed with the two-attending surgeon (neurosurgeon and orthopedic surgeon) model. Demographic information was extracted. Intraoperative complications, including durotomy and direct neurological injury, were queried from the clinical records. Intraoperative neuromonitoring data were evaluated. Postoperative complications were queried, and length of follow-up was determined from the clinical records.

RESULTS

From 2008 to 2019, 22 patients with a median (range) age of 9.1 (2.0-19.3) years underwent hemivertebra resection with the two-attending surgeon, two-specialty model. The median (range) number of levels fused was 2 (0-16). The mean (range) operative time was 5 hours and 14 minutes (2 hours and 59 minutes to 8 hours and 30 minutes), and the median (range) estimated blood loss was 325 (80-2700) ml. Navigation was used in 14% (n = 3) of patients. Neither Gardner-Wells tongs nor halo traction was used in any operation. Neuromonitoring signals significantly decreased or were lost in 14% (n = 3) of patients. At a mean ± SD (range) follow-up of 4.6 ± 3.4 (1.0-11.6) years, 31% (n = 7) of patients had a postoperative complication, including 2 instances of proximal junctional kyphosis, 2 instances of distal junctional kyphosis, 2 wound complications, 1 instance of pseudoarthrosis with hardware failure, and 1 instance of screw pullout. The return to the operating room (OR) rate was 27% (n = 6), which included patients with the abovementioned wound complications, distal junctional kyphosis, pseudoarthrosis, and screw pullout, as well as a patient who required spinal fusion after loss of motor evoked potentials during index surgery.

CONCLUSIONS

Twenty-two patients underwent hemivertebra resection with a two-attending surgeon, two-specialty model over a 12-year period at a specialized children's hospital, with a 14% rate of change in neuromonitoring, 32% rate of nonneurological complications, and a 27% rate of unplanned return to the OR.

Perioperative blood conservation strategies for pediatric scoliosis surgery

PURPOSE

Many pediatric patients with severe scoliosis requiring surgery have baseline anemia. Pediatric scoliosis fusion surgery is associated with perioperative blood loss requiring transfusion. As such, many patients in this surgical population could benefit from a perioperative blood conservation program.

METHODS

Here we present a narrative review of perioperative blood conservation strategies for pediatric scoliosis surgery involving nurses, transfusion medicine physicians, anesthesiologists, surgeons, dieticians, perfusionists and neurophysiologists spanning the pre-, intra- and postoperative phases of care.

RESULTS

The review highlights how perioperative blood conservation strategies, have the potential to minimize exposures to exogenous blood products. Further, we describe a relevant example of blood conservation related to the care of a Jehovah's Witness patient undergoing staged scoliosis repair. Lastly, we outline areas which would benefit from clinical studies to further elucidate perioperative blood conservation interventions and their outcomes relevant to pediatric scoliosis surgery patients.

CONCLUSION

Interdisciplinary communication and meticulous blood conservation strategies are proving to be a means of reducing if not eliminating the need for allogeneic blood products for surgical correction of pediatric scoliosis.

A Two-Surgeon Approach Improves Performance for Young Surgeons in Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is a complex 3-dimensional deformity. Previous studies have suggested a learning curve in the successful execution of this technically demanding procedure. A 2-surgeon model may be helpful for less experienced surgeons by facilitating greater consistency in surgical metrics. The objective of this study was to show no significant difference in the parameters examined for surgeries done by inexperienced primary surgeons with a 2-surgeon model compared with those done by their more experienced cohorts. All surgeries with a primary diagnosis of AIS that were performed from January 2012 to December 2015 and had a minimum of 2-year follow-up were included for analysis. Three groups were created based on surgeon experience: inexperienced surgeons (IS) group, experienced surgeons (ES) group, and a third group where the primary surgeon was in the experienced group and the assistant surgeon was in the inexperienced group (EIS). Variables included for analysis were age, Lenke classification, number of levels fused, length of surgery, length of stay, percent curve correction, ratio of estimated blood loss to levels fused, surgical blood loss, and complications. There were no significant differences between the groups in terms of operative time, blood loss, number of levels fused, lower estimated blood loss ratio to the number of levels fused, or percent curve correction (P>.05). The IS group was found to have a significant shorter length of stay (P=.004). The 2-surgeon model is an effective tool for inexperienced surgeons to achieve consistent and reproducible operative performance that is comparable with their more experienced peers. [Orthopedics. 2021;44(3):e347-e352.].

The value-added benefit of utilizing two attending surgeons for patients with scoliosis secondary to cerebral palsy

PURPOSE

The use of two attending surgeons during posterior spinal fusion (PSF) for cerebral palsy (CP) patients has been shown to improve perioperative outcomes. This study aims to determine if the use of two surgeons is associated with an increase in the number of subsequent surgeries that can be performed in the same operating room (OR) during business hours.

METHODS

Patients with scoliosis and CP treated with PSF with minimum 90-day follow-up were included. Patients were grouped based on whether one or two attending surgeons performed the case. The primary outcome was the number of surgeries that followed in the same OR before 5 PM. Secondary outcomes included operative time, estimated blood loss (EBL), length of stay, rate of surgical site infection, and rate of unplanned return to the operating room.

RESULTS

Thirty-six patients were included (10 with 1 surgeon and 26 with 2 surgeons). The two surgeon group had a significant increase in the average number of surgeries subsequently performed in the same OR during business hours (1.1 vs. 0.3, p = 0.01), as well as shorter mean operative time (159 vs. 307 min, p = 0.007) and EBL (554 vs. 840 cc, p = 0.01; 26 vs. 39%EBV, p = 0.03).

CONCLUSION

The use of two attending surgeons was associated with a significant increase in the number of cases subsequently performed in the same OR during business hours, and significant decreases in operative time and EBL. Hospitals should consider the patient care and potential system-level improvements when considering implementation of two surgeon teams for PSF in CP patients.

LEVEL OF EVIDENCE

Therapeutic Level III.

Single- versus Dual-Attending Surgeon Approach for Spine Deformity: A Systematic Review and Meta-Analysis

BACKGROUND

Surgical management of spine deformity is associated with significant morbidity. Recent literature has inconsistently demonstrated better outcomes after utilizing 2 attending surgeons for spine deformity.

OBJECTIVE

To conduct a systematic review and meta-analysis on studies reporting outcomes following single- vs dual-attending surgeons for spine deformity.

METHODS

MEDLINE, Embase, Web of science, and Cochrane databases were last searched on July 16, 2020. A total of 1013 records were identified excluding duplicates. After screening, 10 studies (4 cohort, 6 case series) were included in the meta-analysis. Random-effect models were used to pool the effect estimates by study design. When feasible, further subgroup analysis by deformity type was conducted.

RESULTS

A total of 953 patients were analyzed. Pooled results from propensity score-matched cohort studies revealed that the single-surgeon approach was unfavorably associated with a nonstatistically significant higher blood loss (mean difference = 421.0 mL; 95% CI: -28.2, 870.2), a statistically significant higher operative time (mean difference = 94.3 min; 95% CI: 54.9, 133), length of stay (mean difference = 0.84 d; 95% CI: 0.46, 1.22), and an increased risk of complications (Mantel-Haenszel risk ratio = 2.93; 95% CI: 1.12, 7.66). Data from pooled case series demonstrated similar results for all outcomes. Moreover, these results did not differ significantly between deformity types (adolescent idiopathic scoliosis and adult spinal deformity).

CONCLUSION

Dual-attending surgeon approach appeared to be associated with reduced operative time, shorter hospital stays, and reduced risk of complications. These findings may potentially improve outcomes in surgical treatment of spine deformity.

Operative time in adolescent idiopathic scoliosis surgery: a need for a standard definition

Our objective is to report and define 'operative time' in adolescent idiopathic scoliosis (AIS) posterior spinal fusion surgeries. Documenting key times during surgery are important to compare operative risks, assess learning curves, and evaluate team efficiency in AIS surgery. 'Operative time' in literature has not been standardized. Systematic review was performed by two reviewers. Keywords included operative time, duration of surgery, and scoliosis. One thousand nine hundred six studies were identified, 1092 duplicates were removed and 670 abstracts were excluded. Of the 144 articles, 67 met inclusion and exclusion criteria. Studies were evaluated for number of patients, operative time, and definition of operative time. Meta-analysis was not performed due to confounders. Of the 67 studies (6678 patients), only 14 (1565 patients) defined operative time, and all specified as incision to closure. From these 14 studies, the median operative time was 248 minutes (range 174-448 minutes). In the 53 studies (5113 patients) without a definition, one study reported time in a non-comparable format, therefore, data were analyzed for 52 studies (5078 patients) with a median operative time of 252 minutes (wider range 139-523 minutes). A clear standardized definition of operative or surgical time in spine surgery does not exist. We believe that operative time should be clearly described for each published study for accurate documentation and be defined from incision time to spine dressing completion time in order to standardize study results. Level of evidence: IV.

Comparison of a dual-surgeon versus single-surgeon approach for scoliosis surgery: a systematic review and meta-analysis

PURPOSE

Corrective surgery for scoliosis is a complex and challenging prospect for experienced spine surgeons due to the prolonged duration of surgery and the significant level of technical skill and expertise required. Traditionally, shorter operative time and lower blood loss have correlated well with improved outcomes and as such, efforts have been made to affect these metrics including the use of two attending surgeons for major cases in preference to one. This systematic review and meta-analysis assessed the available literature to further clarify the potential benefit that adopting a dual-surgeon approach offers over single-surgeon operations.

METHODS

A systematic review and meta-analysis assessed the effect of dual-surgeon operating compared to single-surgeon with respect to a number of indicators including blood loss, operative duration and length of hospital stay. In addition, we evaluated whether blood transfusion or complication rates differed between the two groups.

RESULT

Seven studies met our inclusion criteria. Mean difference indicated shorter duration of surgery (- 90.5 min, 95% CI [- 103.3, - 77.6]) and a lower blood loss (- 379.1, 95% CI [- 572.2, - 230.9]) in the dual-surgeon group compared to the single-surgeon group. Six studies reported mean length of stay and also favoured the dual-surgeon group.

CONCLUSION

This review observed that there are no randomised control trials evaluating dual-surgeon versus single-surgeon operating for scoliosis. We provide aggregated data and analysis of available literature, suggesting that outcomes in complex scoliosis surgery may be improved by adopting a dual-surgeon approach.

LEVEL OF EVIDENCE

III.

Improving Safety and Efficacy in the Surgical Management of Low-tone Neuromuscular Scoliosis: Integrated Approach With a 2-attending Surgeon Operative Team and Modified Anesthesia Protocol

BACKGROUND

Substantially increased operative time and amount of bleeding may complicate the course of surgical treatment in neuromuscular scoliosis. A well-organized team approach is required to reduce morbidity. The aim of this study is to review our early, short-term surgical outcomes with our new integrated approach that includes a 2-attending surgeon team and modifications in the anesthesia protocol in low-tone neuromuscular scoliosis and compare with a matched cohort of our historic patients.

METHODS

We retrospectively reviewed our patients with (1) neuromuscular scoliosis with collapsing spine deformity, (2) low-tone neuromuscular etiology, (3) multilevel posterior column osteotomies with posterior all pedicle screw spinal fusion, and (4) more than 1-year follow-up. Patients were grouped into 2: group 1 consisted of patients managed with the integrated surgical team approach, group 2 included the matched historic patients.

RESULTS

There were 16 patients in group 1 and 17 patients in group 2. There was no significant difference between the groups regarding age, sex, body mass index, number of levels fused, major coronal deformity magnitude, pelvic obliquity, number of posterior column osteotomies, or amount of deformity correction. However, significantly shorter operative time (241 vs. 297 min, P=0.006), less intraoperative bleeding (1082 vs. 1852 mL, P=0.001), less intraoperative blood transfusion (2.1 vs. 3.1 U, P=0.028), less postoperative intensive care unit admission (23% vs. 100%, P=0.001), and shorter hospital stay (4.7 vs. 5.9 d, P=0.013) were observed in group 1.

CONCLUSIONS

Our results indicate that spinal deformity surgery in patients with underlying low-tone neuromuscular disease may not be as intimidating as previously thought. Our surgical team approach integrating a 2-attending surgeon operative team, a new anesthetic protocol that includes a modification of perioperative blood management is effective in reducing operative times, blood loss, transfusion rates, intensive care unit admission, and length of hospital stay.

LEVELS OF EVIDENCE

Level III-retrospective comparative study.

Single- versus dual-attending strategy for spinal deformity surgery: 2-year experience and systematic review of the literature

OBJECTIVE

Adult spinal deformity (ASD) surgery is complex and associated with high morbidity and complication rates. There is growing evidence in the literature for the beneficial effects of an approach to surgery in which two attending physicians rather than a single attending physician perform surgery for and oversee the surgical care of a single patient in a dual-attending care model. The authors developed a dual-attending care collaboration in August 2017 in which a neurosurgeon and an orthopedic surgeon mutually operated on patients with ASD.

METHODS

The authors recorded data for 2 years of experience with ASD patients operated on by dual attending surgeons. Analyses included estimated blood loss (EBL), transfusions, length of stay (LOS), discharge disposition, complication rates, emergency room visits and readmissions, subjective health status improvement, and disability (Oswestry Disability Index [ODI] score) and pain (visual analog scale [VAS] score) at last follow-up. In addition, the pertinent literature for dual-attending spinal deformity correction was systematically reviewed.

RESULTS

The study group comprised 19 of 254 (7.5%) consecutively operated patients who underwent thoracolumbar fusion during the period from January 2017 to June 2019 (68.4% female; mean patient age 65.1 years, ODI score 44.5, VAS pain score 6.8). The study patients were matched by age, sex, anesthesia risk, BMI, smoking status, ODI score, VAS pain score, prior spine surgeries, and basic operative characteristics (type of interbody implants, instrumented segments, pelvic fixation) to 19 control patients (all p > 0.05). There was a trend toward less EBL (mean 763 vs 1524 ml, p = 0.059), fewer intraoperative red blood cell transfusions (mean 0.5 vs 2.3, p = 0.079), and fewer 90-day readmissions (0% vs 15.8%, p = 0.071) in the dual-attending group. LOS and discharge disposition were similar, as were the rates of any < 30-day postsurgery complications, < 90-day postsurgery emergency room visits, and reoperations, and ODI and VAS pain scores at last follow-up (all p > 0.05). At last follow-up, 94.7% vs 68.4% of patients in the dual- versus single-attending group stated their health status had improved (p = 0.036). In the authors' literature search of prior articles on spinal deformity correction, 5 of 8 (62.5%) articles reported lower EBL and 6 of 8 (75%) articles reported significantly lower operation duration in dual-attending cases. The literature contained differing results with regard to complication- or reoperation-sparing effects associated with dual-attending cases. Similar clinical outcomes of dual- versus single-attending cases were reported.

CONCLUSIONS

Establishing a dual-attending care management platform for ASD correction was feasible at the authors' institution. Results of the use of a dual-attending strategy at the authors' institution were favorable. Positive safety and outcome profiles were found in articles on this topic identified by a systematic literature review.

Team Approach: Safety and Value in the Practice of Complex Adult Spinal Surgery

Surgical management of complex adult spinal deformities is of high risk, with a substantial risk of operative mortality. Current evidence shows that potential risk and morbidity resulting from surgery for complex spinal deformity may be minimized through risk-factor optimization. The multidisciplinary team care model includes neurosurgeons, orthopaedic surgeons, physiatrists, anesthesiologists, hospitalists, psychologists, physical therapists, specialized physician assistants, and nurses. The multidisciplinary care model mimics previously described integrated care pathways designed to offer a structured means of providing a comprehensive preoperative medical evaluation and evidence-based multimodal perioperative care. The role of each team member is illustrated in the case of a 66-year-old male patient with previous incomplete spinal cord injury, now presenting with Charcot spinal arthropathy and progressive vertebral-body destruction resulting in lumbar kyphosis.

Perioperative Outcome of Single Stage Posterior Spinal Fusion for Severe Adolescent Idiopathic Scoliosis (AIS) (Cobb Angle ≥90°): The Role of a Dual Attending Surgeon Strategy

STUDY DESIGN

Retrospective study.

OBJECTIVE

To evaluate the perioperative outcome of dual attending surgeon strategy for severe adolescent idiopathic scoliosis (AIS) patients with Cobb angle more than or equal to 90°.

SUMMARY OF BACKGROUND DATA

The overall complication rate for AIS remains significant and is higher in severe scoliosis. Various operative strategies had been reported for severe scoliosis. However the role of dual attending surgeon strategy in improving the perioperative outcome in severe scoliosis has not been investigated.

METHODS

The patients were stratified into two groups, Cobb angles 90° to 100° (Group 1) and more than 100° (Group 2). Demographic, intraoperative, preoperative, and postoperative day 2 data were collected. The main outcome measures were intraoperative blood loss, use of allogeneic blood transfusion, operative time, duration of hospital stay postsurgery, and documentation of any perioperative complications.

RESULTS

Eighty-five patients were recruited. The mean age for the whole cohort was 16.2 ± 5.2 years old. The mean age of Group 1 was 16.7 ± 5.7 and Group 2 was 15.6 ± 4.8 years old. The majority of the patients in both groups were Lenke 2 curves with the average Cobb angle of 93.9 ± 3.0° in Group 1 and 114.2 ± 10.2° in Group 2. The average operative time was 198.5 ± 47.5 minutes with an average blood loss of 1699.5 ± 939.3 mL. The allogeneic blood transfusion rate was 17.6%. The average length of stay postoperation was 71.6 ± 22.5 hours. When comparing the patients between Group 1 and Group 2, the operating time, total blood loss, allogeneic transfusion rate showed significant intergroup differences. Five complications were documented (one intraoperative seizure, one massive blood loss, one intraoperative loss of somatosensory evoked potential (SSEP) signal, and two superficial wound breakdown).

CONCLUSION

Dual attending surgeon strategy in severe AIS more than or equal to 90° demonstrated an average operative time of 199 minutes, intraoperative blood loss of 1.7 L, postoperative hospital stay of 71.6 hours, and a complication rate of 5.9% (5/85 patients). Curves with Cobb angle more than 100° lead to longer operating time, greater blood loss, and allogeneic transfusion rate.

LEVEL OF EVIDENCE

4.

Improving Complex Pediatric and Adult Spine Care While Embracing the Value Equation

INTRODUCTION

Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options.

METHODS

We summarize various methods by which value can be increased in complex spine surgery, both through the improvement of outcomes and the reduction of cost. These methods center around standardization, team-based and collaborative approaches, rigorous outcomes tracking through dashboards and registries, and continuous process improvement.

RESULTS

This manuscript reviews the expert opinion of leading spine specialists on the improvement of safety, quality and improvement of value of pediatric and adult spinal surgery.

CONCLUSION

Without surgeon leadership in this arena, suboptimal solutions may result from the isolated intervention of regulatory bodies or payer groups. The cooperative development of standardized, team-based approaches in complex spine surgery will lead to the high-quality, high-value care for patients.

The Effect of Two Attending Surgeons on the Outcomes of Posterior Spine Fusion in Children With Cerebral Palsy

BACKGROUND

Posterior spinal fusion (PSF) in children with cerebral palsy (CP) carries a high risk of complications and morbidity. The purpose of this study is to investigate the impact of using two attending surgeons on blood loss, operative time, and complications in this fragile population.

METHODS

This was a prospective, matched cohort analysis of patients with CP who underwent PSF with two attending surgeons. These were matched with a control group that had a single-surgeon team, assisted by a senior resident or PA. The groups were compared using paired Student t tests and chi-square tests.

RESULTS

50 patients were included in the study (25 study and 25 matched controls), determined by our power analysis. There was no statistical difference in the mean age, preoperative major curve angle, major curve angle correction, or use of antifibrinolytics. The two-surgeon group decreased surgical time from 5.25 to 3.3 hours (p = .000002), and estimated blood loss from 1,238 to 865 mL (p = .009). The complication rate decreased from 33% to 8% (p=.034). Length of stay was also decreased from 6.5 days to 5.35 (p = .02).

CONCLUSIONS

Although confounding variables were present, this study demonstrates that the use of a two-surgeon team during spinal surgery for patients with cerebral palsy could have a role in reducing operative time, blood loss, complication rates, and hospital length of stay. Overall, these factors and any improved operating room efficiencies may lead to lasting improved patient outcomes.

LEVEL OF EVIDENCE

Level III, retrospective, comparative study.