How Does the Presence of a Surgical Trainee Impact Patient Outcomes in Lumbar Fusion Surgery?

Comparison of Surgical Outcomes After Posterior Decompression by Junior or Senior Surgeons for Patients With Cervical Ossification of the Posterior Longitudinal Ligament: Results From Retrospective Multicenter Cohort Study

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

To investigate surgical outcomes following posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL) when performed by board-certified spine (BCS) or non-BCS (NBCS) surgeons.

METHODS

We included 203 patients with cervical OPLL who were followed for a minimum of 1 year after surgery. Demographic information, medical history, and imaging findings were collected. Clinical outcomes were assessed preoperatively and at the final follow-up using the Japanese Orthopedic Association (JOA) score and the visual analog scale (VAS) for the neck. We compared outcomes between BCS surgeons, who must meet several requirements, including experience in more than 300 spinal surgeries, and NBCS surgeons.

RESULTS

BCS surgeons performed 124 out of 203 cases, while NBCS surgeons were primary in 79 cases, with 73.4% were directly supervised by a BCS surgeon. There was no statistically significant difference in surgical duration, estimated blood loss, and perioperative complication rates between the BCS and NBCS groups. Moreover, no statistically significant group differences were observed in each position of the C2-7 angle and cervical range of motion at preoperation and the final follow-up. Preoperative and final follow-up JOA scores, VAS for the neck, and JOA score recovery rate were comparable between the two groups.

CONCLUSIONS

Surgical outcomes, including functional recovery, complication rates, and cervical dynamics, were comparable between the BCS and NBCS groups. Consequently, posterior decompression for cervical OPLL is considered safe and effective when conducted by junior surgeons who have undergone training and supervision by experienced spine surgeons.

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.

Effect of Fellow Involvement and Experience on Patient Outcomes in Spine Surgery

INTRODUCTION

Investigations in spine surgery have demonstrated that trainee involvement correlates with increased surgical time, readmissions, and revision surgeries; however, the specific effects of spine fellow involvement remain unelucidated. This study aims to investigate the isolated effect of fellow involvement on surgical timing and patient-reported outcomes measures (PROMs) after spine surgery and evaluate how surgical outcomes differ by fellow experience.

METHODS

All patients aged 18 years or older who underwent primary or revision decompression or fusion for degenerative diseases and/or spinal deformity between 2017 and 2019 at a single academic institution were retrospectively identified. Patient demographics, surgical factors, intraoperative timing, transfusion status, length of stay (LOS), readmissions, revision rate, and preoperative and postoperative PROMs were recorded. Surgeries were divided based on spine fellow participation status and occurrence in the start or end of fellowship training. Univariate and multivariate analyses compared outcomes across fellow involvement and fellow experience groups.

RESULTS

A total of 1,108 patients were included. Age, preoperative diagnoses, number of fusion levels, and surgical approach differed markedly by fellow involvement. Fellow training experience groups differed by patient smoking status, preoperative diagnosis, and surgical approach. On univariate analysis, spine fellow involvement was associated with extended total theater time, induction start to cut time, cut to close time, and LOS. Increased spine fellow training was associated with reduced cut to close time and LOS. On regression, fellow involvement predicted cut to close extension while increased fellow training experience predicted reduction in cut to close time, both independent of surgical factors and assisting residents or physician assistants. Transfusions, readmissions, revision rate, and PROMs did not differ markedly by fellow involvement or experience.

CONCLUSION

Spine fellow participation predicted extended procedural duration. However, the presence of a spine fellow did not affect long-term postoperative outcomes. Furthermore, increased fellow training experience predicted decreased procedural time, underscoring a learning effect.

AVAILABILITY OF DATA AND MATERIAL

The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

LEVEL OF EVIDENCE

Level 3.