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Spine surgery

Spinal surgery is taught and practiced within two different surgical disciplines: neurological surgery and orthopedic surgery.

Spinal surgery has become lower risk and more efficacious for complex spinal deformities, and thus more appealing to patients, particularly those for whom conservative treatment is inappropriate or ineffective. Recent innovations and advances in spinal surgery have revolutionized the management of spinal deformity in elderly patients.

The clinical entity lumbar spinal stenosis is the most common reason for spinal surgery in patients 65 years of age and older in the United States.

Recently, intraoperative stereotactic navigation has become more available in spine surgery. Stereotactic navigation with cone-beam fluoroscopy and CT and the use of the O-arm (Medtronic) 3D imaging with stereotactic computer navigation have been well described for the safe and accurate placement of pedicle screws.



Spine surgery has been growing rapidly as a neurosurgical operation, with an increase of 220% over a 15-year period.




Epidural hematomas, cerebrospinal fluid fistula, and spinal infections are challenging postoperative complications following vertebro-spinal procedures.

Most descriptions of spine surgery morbidity and mortality in the literature are retrospective. Emerging prospective analyses of adverse events (AEs) demonstrate significantly higher rates, suggesting underreporting in retrospective and prospective studies that do not include AEs as a targeted outcome.

see Spinal epidural hematoma.

see Spinal cerebrospinal fluid leakage

see Subdural hematoma

see Spinal infection

see Venous thromboembolism.

see Pneumocephalus.

see Spinal epidural hematoma

459 patients who were divided into 5 groups: group 1, patients with cervical degenerative disease treated with posterior decompression; group 2, patients with cervical degenerative disease treated with instrumentation for spinal fusion; group 3, patients with thoracolumbar degenerative disease treated with instrumentation for spinal fusion; group 4, patients with lumbar spinal stenosis treated with posterior decompression; and group 5, patients with lumbar spondylolisthesis treated with 1-level posterior lumbar interbody fusion. A deep venous thrombosis and pulmonary embolism (PE) screening was performed for all patients. Binomial logistic regression analysis was used to assess the association of risk factors.

The incidence of VTE was 2.8%, 3.4%, 10.8%, 12.5%, and 10.1% in groups 1, 2, 3, 4, and 5, respectively. Female sex, advanced age, spinal level, and neurological deficits, were all risk factors. Cervical spinal surgery in particular had an associated low risk. In patients with PE, 3 of the 4 had no deep venous thrombosis, indicating that screening for PE is also needed in high-risk patients.

The prevalence of venous thromboembolism (VTE) after elective spinal surgery was different in each group 1).

Major spinal surgery in adult patients is often associated with significant intraoperative blood loss.

In spine surgery, the incidence of postoperative wound infection is 0.7 to 16% 2) 3).

Although incidence rates are low, adverse events of spinal procedures substantially increase the cost of care. Charges for patients experiencing Deep venous thrombosis (DVT), PE, and surgical site infection (SSI) increased in a study by factors ranging from 1.8 to 4.3 times those for patients without such complications across 5 common spinal and orthopedic procedures. Cost projections by health care providers will need to incorporate expected costs of added care for patients experiencing such complications, assuming that the cost burden of such events continues to shift from payers to providers 4).

Gelfoamis widely used in spine surgery and its complication is rare. Gelfoam has been used to control the bleeding and prevent scar adhesion when used after laminectomy as an effective interposing membrane


For the majority of spinal interventions, well-designed prospective, randomized, pragmatic cost-effectiveness studies that address the specific decision-in-need are lacking. Decision analytic modeling allows for the estimation of cost-effectiveness based on data available to date. Given the rising demands for proven value in spine care, the use of decision analytic modeling is rapidly increasing by clinicians and policy makers.

A proper, integrated, clinical, and economic critical appraisal is necessary in the evaluation of the strength of evidence provided by a modeling evaluation. As is the case with clinical research, all options for collecting health economic or value data are not without their limitations and flaws. There is substantial heterogeneity across the 20 spine intervention health economic modeling studies summarized with respect to study design, models used, reporting, and general quality. There is sparse evidence for populating spine intervention models. Results mostly showed that interventions were cost-effective based on $100,000/quality-adjusted life-year threshold. Spine care providers, as partners with their health economic colleagues, have unique clinical expertise and perspectives that are critical to interpret the strengths and weaknesses of health economic models.

Health economic models must be critically appraised for both clinical validity and economic quality before altering health care policy, payment strategies, or patient care decisions.Level of Evidence: 4 5).

A co-ordinated multidisciplinary pathway with a stratified approach to LBP assessment and care provided a greater proportion of surgery candidates than the conventional referral process. The implementation of such processes may allow surgeons to restrict their practices to patients who are more likely to benefit from their services, thereby reducing wait times and potentially reducing costs.Level of Evidence: 3 6).

In the USA, obesity rates have significantly increased since 2000. Mirroring this trend, a large proportion of patients undergoing spinal surgery are obese 7).

see spinal fusion surgery


The use of simulation in spinal neurosurgery education is not as ubiquitous in comparison to other neurosurgical subspecialties, but many promising methods of simulation are available for augmenting resident education 8).


The spinal surgery community has recently witnessed serious controversies and discussion concerning possible bias in scientific reports on the effects of a commercially available bone morphogenetic protein. This has compromised the standing of this community, and it was the direct reason for performing a study titled 9) 10) 11) 12).


Hospital fee had the largest contribution (75%) to the total cost of index surgery, followed by readmissions (21%). Surgeon's fee and health care resource utilization had much smaller contributions to total cost. True cost savings can occur through engagement and partnering between hospital and surgeon to decrease hospital fees. Reducing readmission episodes and understanding and reducing modifiable drivers of hospital fees have the potential to decrease total direct cost for elective spine surgery 13).

There exists significant variation in total health care costs for patients who undergo spinal surgery, even within a given DRG. Better characterization of impacts of a bundled payment system in spine surgery is important for understanding the costs of index procedure hospital, physician services, and postoperative care on potential future health care policy decision making 14).

Spine Surgery Books

Implementation of an enhanced recovery programme in spine surgery

Minimal literature exists describing the process for development of a Joint Commission comprehensive spine surgery program within a community hospital health system. Components of a comprehensive program include structured communication across care settings, preoperative education, quality outcomes tracking, and patient follow-up. Organizations obtaining disease-specific certification must have clear knowledge of the planning, time, and overall commitment, essential to developing a successful program. Health systems benefit from disease-specific certification because of their commitment to a higher standard of service. Certification standards establish a framework for organizational structure and management and provide institutions a competitive edge in the marketplace 15). 16).

Intraoperative neurophysiological monitoring in spine surgery

Yoshioka K, Murakami H, Demura S, Kato S, Tsuchiya H. Prevalence and risk factors for development of venous thromboembolism after degenerative spinal surgery. Spine (Phila Pa 1976). 2015 Mar 1;40(5):E301-6. doi: 10.1097/BRS.0000000000000727. PubMed PMID: 25494320.
O'Toole J E, Eichholz K M, Fessler R G. Surgical site infection rates after minimally invasive spinal surgery. J Neurosurg Spine. 2009;11(4):471–476.
Schimmel J J, Horsting P P, de Kleuver M, Wonders G, van Limbeek J. Risk factors for deep surgical site infections after spinal fusion. Eur Spine J. 2010;19(10):1711–1719
Daniels AH, Kawaguchi S, Contag AG, Rastegar F, Waagmeester G, Anderson PA, Arthur M, Hart RA. Hospital charges associated with “never events”: comparison of anterior cervical discectomy and fusion, posterior lumbar interbody fusion, and lumbar laminectomy to total joint arthroplasty. J Neurosurg Spine. 2016 Aug;25(2):165-9. doi: 10.3171/2015.11.SPINE15776. Epub 2016 Mar 18. PubMed PMID: 26989978.
Edwards NC, Skelly AC, Ziewacz JE, Cahill K, McGirt MJ. The Role of Decision Analytic Modeling in the Health Economic Assessment of Spinal Intervention. Spine (Phila Pa 1976). 2014 Oct 15;39(22S Suppl 1):S16-S42. PubMed PMID: 25299257.
Wilgenbusch CS, Wu AS, Fourney DR. Triage of Spine Surgery Referrals Through a Multidisciplinary Care Pathway: A Value-Based Comparison With Conventional Referral Processes. Spine (Phila Pa 1976). 2014 Oct 15;39(22S Suppl 1):S129-S135. PubMed PMID: 25299256.
Srinivasan D, La Marca F, Than KD, Patel RD, Park P. Perioperative characteristics and complications in obese patients undergoing anterior cervical fusion surgery. J Clin Neurosci. 2013 Dec 14. pii: S0967-5868(13)00658-9. doi:10.1016/j.jocn.2013.11.017. [Epub ahead of print] PubMed PMID: 24472239.
Bohm PE, Arnold PM. Simulation and resident education in spinal neurosurgery. Surg Neurol Int. 2015 Feb 26;6:33. doi: 10.4103/2152-7806.152146. eCollection 2015. Review. PubMed PMID: 25745588.
Fauber J. “Journal Editor’s Bonanza Research Articles Favor- able to Provider of Royalties Appear with Regularity,” Milwaukee Journal Sentinel. 2009.
Carragee EJ, Ghanayem AJ, Weiner BK, Rothman DJ, Bono CM. A challenge to integrity in spine publications: years of living dangerously with the promotion of bone growth factors. Spine J. 2011; 11: 463–468. doi: 10.1016/j.spinee.2011.06.001
Meier B, Wilson D (2011) Spine Experts Repudiate Medtronic Studies. The New York Times.
Meier B (2013) Outside Review of Clinical Data Finds a Spinal Treatment’s Benefit Overstated. The New York Times.
Parker SL, Chotai S, Sivaganesan A, Devin CJ, McGirt MJ. 146 Where Does Potential for True Cost Savings Exist Following Elective Surgery for Degenerative Spine Disease? Neurosurgery. 2015 Aug;62 Suppl 1:213. doi: 10.1227/01.neu.0000467108.45053.ce. PubMed PMID: 26181992.
Ugiliweneza B, Kong M, Nosova K, Huang KT, Babu R, Lad SP, Boakye M. Spinal surgery: variations in health care costs and implications for episode-based bundled payments. Spine (Phila Pa 1976). 2014 Jul 1;39(15):1235-42. doi: 10.1097/BRS.0000000000000378. PubMed PMID: 24831503.
Koerner K, Franker L, Douglas B, Medero E, Bromeland J. Disease-specific Care: Spine Surgery Program Development. J Neurosci Nurs. 2017 Aug 16. doi: 10.1097/JNN.0000000000000307. [Epub ahead of print] PubMed PMID: 28817500.
Popat K, Grasu R, Tatsui C, Bird J, Cahoun J, Cata J, Bhavsar S, Rhines L. Implementation of an enhanced recovery programme in spine surgery. Clin Nutr ESPEN. 2016 Apr;12:e47. doi: 10.1016/j.clnesp.2016.02.054. Epub 2016 Apr 1. PubMed PMID: 28531717.
spine_surgery.txt · Last modified: 2018/11/18 09:13 by administrador