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

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.

Same-Day Versus Staged Spinal Fusion: A Meta-analysis of Clinical Outcomes

STUDY DESIGN

Meta-analysis.

OBJECTIVE

This meta-analysis aims to compare same-day versus staged spine surgery, assessing their effects on patient care and health care system efficiency.

BACKGROUND

In spinal surgery, the debate between whether same-day and staged surgeries are better for patients continues, as the decision may impact patient-related outcomes, health care resources, and overall costs. While some surgeons advocate for staged surgeries, citing reduced risks of complications, others proclaim same-day surgeries may minimize costs and length of hospital stays.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up until February 2024. The studied outcomes were operative room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), overall complications, venous thromboembolism (VTE), death, operations, and nonhome discharge.

RESULTS

Sixteen retrospective studies were included in this meta-analysis, representing a total of 2346 patients, of which 644 underwent staged spinal fusion surgeries and 1702 same-day surgeries. No statistically significant difference was observed in EBL between staged and same-day surgery groups. However, the staged group exhibited a statistically significant longer OR time ( P =0.05) and LOS ( P =0.004). A higher rate of overall complications ( P =0.002) and VTE ( P =0.0008) was significantly associated with the staged group. No significant differences were found in the rates of death, reoperations, and nonhome discharge between the 2 groups.

CONCLUSIONS

Both staged and same-day spinal fusion surgeries showed comparable rates of death, operations, and nonhome discharges for patients undergoing spinal surgeries. However, given the increased OR time, LOS, and complications associated with staged spinal surgeries, this study supports same-day surgeries when possible to minimize the burden on healthcare resources and enhance efficiency.

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.

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.

Advances and Evolving Challenges in Spinal Deformity Surgery

BACKGROUND

Surgical intervention is a critical tool to address adult spinal deformity (ASD). Given the evolution of spinal surgical techniques, we sought to characterize developments in ASD correction and barriers impacting clinical outcomes.

METHODS

We conducted a literature review utilizing PubMed, Embase, Web of Science, and Google Scholar to examine advances in ASD surgical correction and ongoing challenges from patient and clinician perspectives. ASD procedures were examined across pre-, intra-, and post-operative phases.

RESULTS

Several factors influence the effectiveness of ASD correction. Standardized radiographic parameters and three-dimensional modeling have been used to guide operative planning. Complex minimally invasive procedures, targeted corrections, and staged procedures can tailor surgical approaches while minimizing operative time. Further, improvements in osteotomy technique, intraoperative navigation, and enhanced hardware have increased patient safety. However, challenges remain. Variability in patient selection and deformity undercorrection have resulted in heterogenous clinical responses. Surgical complications, including blood loss, infection, hardware failure, proximal junction kyphosis/failure, and pseudarthroses, pose barriers. Although minimally invasive approaches are being utilized more often, clinical validation is needed.

CONCLUSIONS

The growing prevalence of ASD requires surgical solutions that can lead to sustained symptom resolution. Leveraging computational and imaging advances will be necessary as we seek to provide comprehensive treatment plans for patients.

Postoperative Radiological Improvement after Staged Surgery Using Lateral Lumbar Interbody Fusion for Preoperative Coronal Malalignment in Patients with Adult Spinal Deformity

This retrospective observational study evaluated improvement in coronal malalignment (CM) after anteroposterior staged surgery using lateral lumbar interbody fusion (LLIF) in patients with coronal lumbar curve adult spinal deformity (ASD). Sixty patients with ASD underwent surgery; 34 had SRS-Schwab type L lumbar curve. Patients with a coronal balance distance (CBD) ≥20 mm were diagnosed with CM. Using the Obeid CM classification, we classified the preoperative coronal pattern as concave CM (type 1) or convex CM (type 2). Demographic, surgical, and radiological parameters were compared. Whole-spine standing radiographs were assessed preoperatively and postoperatively. Twenty-three patients had type 1A, six had type 2A, five had no CM, and none had type 1B or 2B according to the Obeid CM classification. Compared with patients with Obeid type 1A, those with Obeid type 2A had significantly higher preoperative and postoperative coronal L4 tilts and a smaller change in corrected CBD (Δ|CBD|) (76.6 mm vs. 24.1 mm, p < 0.001). At the final follow-up, 58.6% (17/29 patients) of patients with SRS-Schwab type L CM showed improvement after corrective fusion using LLIF. Although the difference was not statistically significant, CM improved in 69.6% (16/23 patients) of patients with Obeid type 1A type but only 16.7% (1/6 patients) of those with Obeid type 2A type (p = 0.056). CM was more likely to remain after anteroposterior staged surgery using LLIF in patients with preoperative Obeid type 2A ASD.

Duplicated Reality for Co-located Augmented Reality Collaboration

When two or more users attempt to collaborate in the same space with Augmented Reality, they often encounter conflicting intentions regarding the occupation of the same working area and self-positioning around such without mutual interference. Augmented Reality is a powerful tool for communicating ideas and intentions during a co-assisting task that requires multi-disciplinary expertise. To relax the constraint of physical co-location, we propose the concept of Duplicated Reality, where a digital copy of a 3D region of interest of the users' environment is reconstructed in real-time and visualized in-situ through an Augmented Reality user interface. This enables users to remotely annotate the region of interest while being co-located with others in Augmented Reality. We perform a user study to gain an in-depth understanding of the proposed method compared to an in-situ augmentation, including collaboration, effort, awareness, usability, and the quality of the task. The result indicates almost identical objective and subjective results, except a decrease in the consulting user's awareness of co-located users when using our method. The added benefit from duplicating the working area into a designated consulting area opens up new interaction paradigms to be further investigated for future co-located Augmented Reality collaboration systems.

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.