December 15, 2021

New research suggests a pathway geared toward the entire perioperative journey could improve outcomes, reduce hospital stays.

Pamela Bevelhymer
GROUP EFFORT A team of multi-disciplinary providers meets the various clinical needs of patients throughout the entire perioperative process.

Surgeons from the Hospital for Special Surgery (HSS) recently tested the effectiveness of their new enhanced recovery pathway for complex spinal fusion patients — and they were quite encouraged by what they found.

Specifically, the HSS team compared patients who underwent spinal fusions of at least five vertebrae in their lower back using the enhanced recovery pathway with patients who were cared for without the optimized pathway and published their findings in The Spine Journal.

The HSS pathway, which included a meticulous patient selection process, focused on every phase of the surgical journey and stressed continuity. The same surgical team (including techs, nurses and anesthesiologists) was used for each procedure and the same physical therapists cared for the patients post-op. Additionally, all patients in the pathway were mobilized three times per day. Intraoperatively, the procedures were performed in four, one-hour stages so the OR team could anticipate the upcoming stage. In the post-op phase, pain medication was reduced in an effort to decrease narcotics-based complications, patients were required to get out of bed the day of surgery (previously, they waited until the day after) and PT sessions increased to three times per day (up from twice daily).

Notably, not one of the patients from the enhanced recovery pathway required transfer to the intensive care unit, compared with the 30% rate for non-optimized patients. Plus, hospital stays decreased from 7.3 days to 4.5 days for optimized patients, and 95% of these patients were discharged to their homes versus just 65% of the non-optimized patients, who were sent to rehab facilities.

While pleased with the findings, principal investigator and HSS spine surgeon Han Jo Kim, MD, did acknowledge the difficulty some facilities may face in reproducing such an intensive pathway. However, he notes the results of the study would ultimately benefit facilities in many ways.

"HSS is uniquely positioned to execute a program of this kind, because everyone here is dedicated to orthopedic surgery and care. That enables us to create and initiate optimized pathways," he says. "Not every hospital has the infrastructure and resources to build this type of program, but we wanted to share what we did so other centers could model it. Ultimately, the goal is to improve the quality of care that we provide for patients and to decrease the costs by instituting such pathways across multiple healthcare systems in the country that care for complex spine patients."

Researchers identify positive outcomes in terms of accuracy, surgical times and patient complications.

Hospital for Special Surgery
FAST FORWARD Darren Lebl, MD, MBA, believes technological advancements in spine ORs have reached a tipping point.

Robotics and computer navigation are being used in spinal surgery to enhance precision, accuracy and predictability, but how well are these systems and the surgeons who employ them working? A new study from Hospital for Special Surgery (HSS) in New York City finds they're performing quite well.

Darren R. Lebl, MD, MBA, an HSS spine surgeon and one of five HSS co-authors of the study, characterized the technologies as having reached a tipping point. "I think they're good enough to greatly improve what we do in terms of minimally invasive surgery," he says. "In my own practice, I've seen the benefits for patients in terms of a shorter hospital stay, quicker mobility and decreased healing times."

The main barriers to implementing the technologies, the authors say, include additional time required in the OR and concerns regarding the accurate placement of pedicle screws. As such, the study, published in The Journal of Spine Surgery, examined the records of dozens of patients operated on by a single surgeon to evaluate the accuracy of robotic- and navigation-assisted technology in screw placement, as well as to determine the extra time needed for the technologies to be used.

Mean time per screw placement was 3.6 minutes robotically versus 3.7 minutes freehand, but the time it took to place screws robotically decreased significantly between the surgeon's first 10 and last 10 cases, at 5.5 minutes versus 2.3 minutes. Similar improvements with experience were noted in terms of setting up the robotic navigation system in the OR between the first 10 and last 10 cases: nine minutes versus six minutes.

"Our main finding was that the screw positioning was very accurate, and the additional time needed to adopt these technologies into practice was small," says Dr. Lebl. "The benefits of the technology easily outweigh the additional time needed in the early implementation of the system because the accuracy is unmatched."

Patients in that study experienced no complications, and none required revision surgeries. The surgical team learned how to use the robot successfully and became more efficient with robotic implantation when compared to conventional minimally invasive and conventional open techniques, according to Fedan Avrumova, BS, a research assistant in the HSS spine service. In addition, he says, the accuracy was as good as, if not better than, open or conventional minimally invasive techniques, which we confirmed with a 3D imaging study in every patient during surgery.

"Just a few years ago, there were two FDA-approved robots to assist in spine surgery. Now there are five or six," says Dr. Lebl. "The technology is revolutionizing the way we do things, and it's a very exciting time to be a spine surgeon."

Raising awareness is key to promoting optimal care for painful VCFs.

CREDIT: Madison Memorial Hospital
David Christensen, MD.

Sooner is better than later. That's the message that Dr. David Christensen has shared with fellow physicians in Twin Falls, Idaho, about how to treat patients who have painful vertebral compression fractures.

Christensen, an orthopedic surgeon in private practice, favors treating these patients with vertebral augmentation via Balloon Kyphoplasty, when appropriate. He has built relationships with emergency room physicians and hospitalists at the sole hospital in the area to help optimize care of VCF patients.

"I've tried to show them studies and statistics that patients do get better with kyphoplasty," Christensen says.

"The referral pattern has an impact on their health. The sooner we can get to them, the better -- even for inpatients. The hospitalists learned that if they treat them themselves, they're there for a week or 10 days and then they go to the nursing home. If they call me, I do a kyphoplasty and sometimes they go home the same day or the next day."

Balloon Kyphoplasty is a minimally invasive procedure for the treatment of spinal fractures due to osteoporosis, cancer or noncancerous tumors.

Christensen cited a recent case involving an 80-year-old woman with osteoporosis who fell at home. She went to the ER, where an X-ray found she had a fracture at her T12 vertebra. She was prescribed a pain reliever and sent home with instructions to contact Christensen's office.

"She fell on the first of the month, we saw her on the 10th for her initial evaluation, and we had her kyphoplasty done on the 12th," Christensen says. After having been confined mostly to her recliner for almost two weeks, the patient was able to get up and walk out of the hospital after her procedure. She reported no pain at the treated level upon follow-up at the end of the month.

Although the complication rate for Balloon Kyphoplasty 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.

Christensen said ensuring patients get follow-up treatment for their osteoporosis is vital to preventing further fractures.

"At the time of the fracture and on post-op follow-up, we talk about the osteoporosis diagnosis and treatment, calcium and vitamin D supplementation as well as further treatment," he says. "We go over the medications, and we refer them back to their primary care with recommendations."

Christensen says while there is more work to do in his community to raise awareness about optimal care for painful VCFs, his results speak for themselves.

"In my practice, the vast majority of the time, patients notice significant improvement in pain with 12 to 24 hours," says Christensen.

Note: The preceding testimonial contains the opinions of and personal surgical techniques practiced by Dr. David Christensen. The opinions and techniques presented herein are for information purposes only, and the decision of which technique 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.

Note: For more information, please go to https://www.medtronic.com/us-en/healthcare-professionals/therapies-procedures/spinal-orthopaedic/vertebral-augmentation/procedural-solutions/balloon-kyphoplasty.html?cmpid=Article_TradePublication_OutpatientSurgeryArticle4_DrDavidChristensen_UC202207584EN_BKP_FY22.

Following evidence-based criteria produces better surgical outcomes.

A study of 325 lumbar fusion cases showed that using clinical guidelines to select patients for the increasingly popular procedure that alleviates chronic back pain produced a threefold increase in successful outcomes.

The study was conducted by researchers at Thomas Jefferson University in Philadelphia because, while the increase of lumbar fusions since the 1990s is well documented (lumbar fusions accounted for only 14% of reimbursements for back surgeries in 1992 and jumped to 47% by 2003), much less is known about the outcomes of the procedures — and whether clinical guidelines were used to choose the patients.

Researchers assessed whether the 325 patients conformed to the North American Spine Societies (NASS) lumbar fusion guidelines, which include factors such as trauma, spine deformities, certain types of axial back pain, tumor and infection. The study notes that debate continues as to when patients fit the NASS criteria for the procedure.

The study, published in the journal Neurosurgery, shows that lumbar fusions were three times more likely to have better outcomes when the surgery was appropriate for them. The opposite was also true, showing that patients not best suited for the procedure based on evidence-based literature could have increased pain, other limitations or at least not see significant improvements in their quality of life.

"Unfortunately, we don't know how many lumbar fusion surgeries are not based on evidence-based best practice, or how these patients do clinically," says neurosurgeon James Harrop, MD, MSHQS, professor and the chief of Jefferson Health's Vickie and Jack Farber Institute for Neuroscience's Spine and Peripheral Nerve Surgery Division. "The study goal was to explore what drove the best clinical outcomes for lumbar fusion, specifically the outcomes that patients valued as important to them."

After six months, patients were asked about quality-of-life measures such as pain, walking, lifting, sleep, social life and sex life. Concordance with the NASS guidelines was most strongly associated with positive outcomes, more so than other variables such as the type of surgeon who performed the procedure and whether it was the patient's first back surgery or a revision.

"This study shows that the majority of patients did well with a lumbar fusion," says Dr. Harrop. "But for the wrong patients, lumbar fusion can at best do nothing and at worst, create other problems."

Researchers hope to identify patients at risk for suffering debilitating dysphagia.

Researchers at NYU Langone Health in New York City are determined to find out why some patients have difficulty swallowing for several months after undergoing anterior cervical discectomy and fusion (ACDF) surgery. At this point, little is known about the post-op complication.

Swelling after surgery can cause temporary disruption of a patient's ability to swallow for a few months following ACDF, but concerns increase when the condition persists. The researchers point out that long-term dysphagia can cause aspiration, which can also lead to pneumonia.

"ACDF patients almost universally experience some disruption to their swallowing, since they've had their neck opened and an invasive procedure in that space," says Sonja Molfenter, PhD, an associate professor in the department of communicative sciences and disorders at NYU Steinhardt School of Culture, Education and Human Development. "What's less understood is how to identify which patients experience changes to the neurovascular structures involved in swallowing, or why and how a subset of these patients go from being disrupted during postsurgical recovery to longstanding dysphagia."

Dr. Molfenter and colleagues reviewed the issue in 2,000 published studies and found almost half of them employed a yes/no analysis to determine if spine patients suffered from swallowing difficulties after surgery. He says that type of question isn't sufficient to determine the extent of the symptoms and what caused them.

"When we follow these patients at our center, we typically perform a much more in-depth radiographic assessment, with a barium swallow, to assess the extent of structural involvement in the patient's symptoms," says Stamatela Matina Balou, PhD, a clinical assistant professor in the department of otolaryngology-head and neck surgery at NYU Steinhardt. Dr. Balou is teaming with Dr. Molfenter and others to test ACDF patients with a swallowing study, measures of pharyngeal edema with an acoustic pharyngometer and an acoustic voice sample to determine if it's possible to predict which patients will experience debilitating issues with swallowing.

"Currently, by the time patients come to us with symptoms, they have already suffered for several months," says Dr. Balou. "If we can identify an algorithm that would let surgeons know a patient is high-risk for long-term problems, we could recognize what's happening and intervene at patients' first complaint to potentially restore their quality of life sooner."