Spine surgery

Spine 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.

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 1).

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 2).

In the USA, obesity rates have significantly increased since 2000. Mirroring this trend, a large proportion of patients undergoing spinal surgery are obese 3).

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 4).

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 5) 6) 7) 8).

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 9). 10).

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.
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.
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