December 3, 2020

Communication is key as patients consult outside sources for information.

Managing expectations is important in many walks of life, but perhaps none more so than in the world of surgery. That was the focus of a longitudinal investigation involving hundreds of patients by the Hospital for Special Surgery (HSS) in New York City that found surgeons should feel highly confident in the outcomes they predict for lumbar spine surgery, but they also need to make sure their patients are on the same wavelength.

HHS reported that surgeons' preoperative expectations were more accurate than patients' expectations in predicting patient-reported outcomes two years after lumbar spine surgery. The institution identified a related problem that led to this mismatch: "Most patients had higher expectations than their surgeons did, with many anticipating complete improvement after seeking additional information beyond that provided by their surgeons."

Federico P. Girardi, MD, an attending orthopedic surgeon at HSS, says that despite advances in spine surgery this century like minimally invasive and robotic approaches that have led to improved outcomes, patients' perceptions of the outcomes these procedures provide vary.

"Some patients report they are not doing well compared with others with similar conditions who received the same surgeries," says Dr. Girardi. "That has been very frustrating for surgeons because our goal is to optimize patient outcomes."

Carol A. Mancuso, MD, FACP, a general internist and clinical epidemiologist at HSS, adds, "Unrealistically high or low expectations are problematic, predisposing patients to poor outcomes if they become discouraged with recovery, abandon rehabilitation or ignore recommended lifestyle modifications that reduce disease progression."

As part of the HSS Lumbar Spine Surgery Expectations Survey, Drs. Girardi, Mancuso and others collected input from 402 patients over several years on the surgical outcome factors that matter most to them, exploring issues like symptom relief, resumption of activities and, in a new twist, psychological well-being, which previous surveys didn't capture.

They asked the patients and their surgeons to preoperatively assess their expectations of patient-reported surgical outcomes on a scale of 0 to 100, where a higher score indicates higher expectations. Two years after surgery, they surveyed patients again to evaluate their satisfaction. Surgical procedures ranged from a single herniated disc removal to more complex operations such as a five-level anterior-posterior decompression, instrumentation and fusion.

Patients' average preoperative score in the study was 73, with the surgeons at 57. Investigators then determined whose presurgical expectations more closely predicted postoperative fulfillment of those expectations, as reported by patients. In 73% of cases, surgeons either predicted patients' reported outcomes exactly or patients surpassed surgeons' expectations. Dr. Mancuso says the results show that HSS spine surgeons "very accurately" predicted patient-reported outcomes two years after surgery, adding the results show the surgeons' aptitude at integrating "complex clinical, surgical and psychological factors that matter most to patients."

One final finding shows how important effective patient-surgeon communication is for a patient's overall experience. HSS said 84% of patients had higher expectations than their surgeons, often expecting complete improvement. When they drilled down, investigators found many of those patients had "amplified" their surgeons' guidance with information they obtained from family, friends, coworkers and the internet.

"Our study underscores that there is room for improvement in patient education and that patients should rely on their surgeon's expertise when forming expectations of lumbar spine surgery," says Dr. Girardi. "Patients need to realize that anecdotal stories from social contacts or the internet are often not relevant to their situation."

Matching the right surface to specific procedure is vital.

Surgical tables specially designed for spine procedures are no-brainers for facilities with large or growing spinal surgery programs, or those looking to expand into the discipline. It can feel a bit overwhelming to evaluate the various features and capabilities of the available choices, so you'll definitely want to consult your surgeons on their needs and preferences.

For Sheeraz Qureshi, MD, MBA, the Patty and Jay Baker endowed chair in minimally invasive spine surgery at the Hospital for Special Surgery, and associate professor of orthopedic surgery at Weill Cornell Medical College in New York City, the top-line concerns are access, visibility, versatility, positioning and control.

Spine tables generally offer interchangeable tops optimized for different types of procedures. That versatility, notes Dr. Qureshi, is especially important for outpatient facilities. "You want to invest in one table on which you can swap different attachments and accessories that are easy to store and don't take up a lot of space," he says.

In that vein, he also advises to look for spine tables with radiolucent surfaces to accommodate intraoperative imaging, along with a base that doesn't need to be changed, regardless of the type of spinal procedure performed and tabletop used.

"This certainty about the table's footprint is well-suited to space-conscious surgery centers, where the goal is to keep OR setups as uniform and cookie-cutter as possible," says Dr. Qureshi. "Because the uniform base of the table always remains a constant, no matter what top is used, it provides predictability for both staff and administration. It never becomes a limiting factor in terms of the surgeries you can perform."

This uniformity, he adds, also helps with turnover times, because you don't need to move different tables in and out of the same OR to accommodate various types of spine surgeries. Another advantage: A uniform base breeds familiarity, which makes it easier for the surgeon and staff to move around the OR, maneuver fluoroscopy units and other equipment around the table, and also store equipment underneath its surface.

The ability to reconfigure the top of the table with minimum fuss is key, too. "I work with a flat top for cases such as anterior cervical or lumbar fusion procedures where the patient is lying flat on their back," explains Dr. Qureshi. "If a patient is placed in the prone position, we'll often add a Wilson frame, which provides padding for the patient's face and chest, and naturally positions them in a neutral posture that enables me to access the posterior part of the spine."

Spine tables still have room for improvement. "I perform a lot of minimally invasive surgeries that involve the use of tubular retractors, the arms of which connect to the table to ensure the retractor stays exactly where I want it while it's inside the patient," says Dr. Qureshi.

The problem: the area where the arm connects is through a holder that wasn't designed for the table. "We end up jury-rigging the set-up, but I'd like to see manufacturers expand my options for how to attach these arms to tables," he says.

Early intervention, solution to reduce pain can limit complications in this new pathway and improve treatments for patients who present with VCF

Dr. Joseph Farnam saw an opportunity to improve treatment of patients who came to his hospital in severe pain due to vertebral compression fractures (VCFs). A recently published care pathway provided a solution.

Farnam, a diagnostic and interventional radiologist at Newport Hospital in Rhode Island, was concerned about inconsistent treatment of patients who presented at the emergency department (ED) with painful vertebral compression fractures. VCFs are the most common type of fragility fracture, occurring more than 800,000 times a year in the U.S. alone.¹

"I would see the imaging, and I would use that to reach out to clinicians and make sure that these patients are at least given the option for treatment with vertebral augmentation, especially patients that would benefit the most that are in severe pain or functionally disabled," Farnam says.

There was, however, no workflow to manage these patients in an acute inpatient setting or to follow up with them for outpatient treatment.

Working with a colleague at a larger hospital in the same health system along with consultants from Medtronic, the team approached the administration about instituting a VCF care pathway developed by a multispecialty panel of experts using the RAND Appropriateness Method.²

"We got together and tried to formulate a way that we could implement that pathway throughout the health care system so that we have consistency across all affiliates," says Farnam.

VCFs can be clinically challenging to diagnose and treat. An ED physician treating a patient with debilitating back pain might prescribe opioid pain medication to mask the symptoms without fixing the underlying problem. That can lead to patients returning for additional care once the prescription is up.

Patients with VCFs can experience complications related to their pain and limited mobility, including pneumonia, blood clots and digestive problems.²

"There's other kinds of effects of not treating the fracture, so that would also play into readmission rates," explains Farnam.

Farnam informs that he favors early intervention using vertebral augmentation, which can reduce the cycle of pain, limit the downward spiral of complications, and lower mortality risks.^3-10

Medtronic developed balloon kyphoplasty, a minimally invasive procedure that reduces and stabilizes VCF related to osteoporosis, cancer or non-cancerous tumors. Since the initial technology launched in 1998, Medtronic has developed better balloons, an improved cement delivery system and added access tools shown to reduce hand radiation exposure for the surgeon. Over the years, studies comparing balloon kyphoplasty to non-surgical management have shown balloon kyphoplasty produced better pain relief and quality of life for patients with acute VCF compared to patients treated with non-surgical management.^7-10

Although the complication rate for BKP is low, as with most surgical procedures, serious adverse events, some of which can be fatal, can occur, including heart attack, cardiac arrest (heart stops beating), stroke, and embolism (blood, fat, or cement that migrates to the lungs or heart). Other risks include infection; leakage of bone cement into the muscle and tissue surrounding the spinal cord and nerve injury that can, in rare instances, cause paralysis; leakage of bone cement into the blood vessels resulting in damage to the blood vessels, lungs, and/or heart.

"If patients don't need to be admitted, then we should try to avoid that as much as possible," Farnam says. "I think that it's easier for ED docs to discharge a patient if they know there's a robust plan in place to be evaluated and potentially treated quickly after their initial evaluation."

After getting buy-in from hospital administration, Farnam said the next step was integrating the care pathway into the electronic medical records system.

"The way we're going to do it is it's a BPA, a best practice advisory. It's an alert that comes up in our Electronic Medica Record system (EMR) – a pop-up window when certain patient characteristics are met that reminds a clinician that they're dealing with this specific disease process and these are the recommendations," Farnam explains.

To learn more about VCF Carepathway, visit medtronic.com/vcfcarepath.

Note: The following testimonial contains the opinions of and personal surgical techniques practiced by Joseph Farnam, M.D. The opinions and techniques presented herein are for information purposes only and the decision of which techniques to use in a particular surgical application should be made by the surgeon based on the individual facts and circumstances of the patient and previous surgical experience.

There are several steps you can take to mitigate the risks.

It's alarmingly easy for spine surgery patients placed in the prone position to develop pressure injuries (PIs) on areas of their bodies that don't have much natural protection. Fortunately, a variety of products and practices can help keep skin intact during complex, lengthy spine cases. Joyce Black, PhD, RN, CWCN, FAAN, an associate professor in the College of Nursing at the University of Nebraska Medical Center in Omaha, recently shared these pressure injury prevention tips with Outpatient Surgery Magazine.

• Perform pre-op assessments. Check the patient's skin integrity for potential trouble spots. "Everyone's body habitus is different," notes Dr. Black, who says to look for red flags like chest deformities or prominent sets of ribs. "Pad these areas as appropriate," she notes. "In general, focus on protecting a patient's face, chest, chin and ribs." Dr. Black recommends using the Scott or Munro trigger scales for predicting potential PIs.
• Consider the length of surgery. Dr. Black identifies the duration of the surgery as the biggest risk factor for PIs. "Any procedure lasting longer than 2.5 hours increases the likelihood of skin breakdown," she notes.
• Factor in the ASA score. "Patients with ASA scores of 3 and 4 have a higher risk than those with 1 or 2 — and there's a huge jump in risk between scores of 2 and 3," says Dr. Black, adding that operations are often longer for patients with higher ASA scores due to the need for additional time to manage their underlying or comorbid diseases. "Don't be fooled into thinking that a young healthy person having a multilevel spinal fusion that will take several hours is not at risk," she adds.
• Use the right OR table. Some OR tables work better for maintaining the skin integrity of patients in the prone position. "Any well-padded surface that holds the patient in the jumping jack position allows surgeons to get as close as possible to the patient's spine as they work," says Dr. Black. "Others are designed with an opening to free up space around the abdomen. These tables are needed, especially for individuals with high BMIs, to reduce pressure on the abdomen, blood vessels and liver. The edges of the area in which the abdomen drops into create the potential for PIs, so padding the patient's body where it meets these edges is crucial."
• Apply proper padding. Adhesive dressings and egg crate foam adequately protect sensitive areas such as elbows and shoulders. Fluidized positioning pillows can mold to the part of the body you want to protect. Dr. Black advises avoiding regular pillows, which gradually compress from the patient's weight. Also pad the surface of the table itself. "Make sure the padding on whatever frame you use is still functional," says Dr. Black. "There should be at least four inches of foam that still has its memory and hasn't worn out." An easy way to test for this, she says, is to push your hand into the foam. If the foam is functional, your handprint will quickly disappear. Other padding options include gel pads, mattresses that inflate and deflate during surgery to relieve pressure from the abdominal area, and "waffle mattresses" whose small air pockets and vents prevent moisture from forming on patients' skin.
• Rely on pressure sensors. Pressure sensors, some the size of the OR table's surface, some as small as four-by-four inches, can help determine where patients are most PI-susceptible. These sensors detect the interface pressure between the body and the tabletop, map the problem points using color codes, and render them on a monitor. Hot spots appear as different colors; you can then pad the patient in those areas, or place better padding on those parts of the table.
• Reexamine in PACU. Even though most PIs don't appear for about 48 hours after a procedure, it's important to check problem areas for potential damage before the patient leaves the facility.
• Follow up. Ask patients during post-op phone calls if any deep-tissue PIs have formed. "They appear as bruising, or manifest as pain in areas of the body exposed to pressure during surgery, so be sure to ask about discomfort in the face, shoulders, ribs and lower legs," says Dr. Black.

The hybrid learning program intends to further the knowledge of spine specialists globally.

Chicago-based Rush University's Center for Innovative and Lifelong Learning (CILL), which had focused mainly on orthopedics, has expanded into spine with the November launch of its Rush International Spine Education (RISE) initiative. Rush calls the program "the world's first academically-supported international program in blended learning for spine specialists, including both clinicians and researchers."

Blended learning is a hybrid, mostly self-paced experience that combines online education with in-person, interactive contact instruction in the field. Says Rush, "It requires the physical presence of both teacher and student, and combines that with a student's control of certain elements like time, place, path and even pace. This type of interactive learning can elevate and complement a specialist's learning experience with both theoretical knowledge and practice skills."

RISE curriculum addresses diagnosis, treatment, outcomes and preventative measures of various spinal disorders. Senior faculty serve as mentors to each registered participant for the year, and case-based tutorials will be provided via monthly, interactive webinars. An example of the subject matter: The first topic in the RISE series is about the common spine condition of cervical radiculopathy and myelopathy. The module includes 13 lectures that "cover everything from the basic science and clinical assessment to both non-operative and operative management and surgical outcomes," says Rush.

The program is open to residents, fellows, junior clinicians and senior clinicians seeking a refresher, says Rush. Students receive an academic certificate of completion and Continuing Medical Education (CME) credit, specifically AMA PRA Category 1 Credit. Surgeons can learn more and register here.