Multidisciplinary Approach to Reducing Complications of Complex Spine Surgery
Minor and major complication rates are known to be quite high – as high as 70% – in adults who undergo surgery to treat complex spinal deformities.
What can be done to decrease adverse outcomes in these patients? At NYU Langone, the answer is preoperative case conferences, initiated in February 2019. This approach is common in medical specialties, but not often utilized in spine surgery.
The multidisciplinary team members participating in the case conferences include clinical specialists in orthopaedic spine surgery, neurosurgery, anesthesia, intraoperative monitoring neurology, and neurological intensive care. The team meets weekly to:
- Review high-risk spinal deformity cases
- Determine which patients are the best candidates for surgery
- Develop comprehensive, multidisciplinary treatment plans
To determine whether the multidisciplinary case conference approach has been effective, the team evaluated outcomes in high-risk spinal deformity patients who had undergone surgery between January 1, 2017, and October 31, 2020, at NYU Hospital for Joint Diseases/NYU Langone Orthopedic Hospital. Patients referred for presentation at the case conference had at least 1 of the following criteria:
- 8+ levels fused
- Osteoporosis with 4+ levels fused
- 3-column osteotomy
- Anterior revision of the same lumbar level
- Severe myelopathy
- Scoliosis (>75°)
- Kyphosis (>75°) with planned significant correction
The study included 263 patients:
- 167 had undergone spine surgery before the conference began (ie, surgery before February 19, 2019)
- 96 who had undergone spine surgery after the conferences began (ie, surgery after February 19, 2019)
Patients in the before-conference group were an average of 54.6 years old, while the after-conference group were an average of 60 years old. The after-conference group had a lower BMI than the before-conference group: 27.1 vs 28.9. Both groups had similar demographics, with a majority of female patients in each (about 70%); similar comorbidity rates, based on the Charleson Comorbidity Index; and similar ASA classifications.
The primary endpoints were complications (intraoperative and perioperative), 30- and 90-day readmission rates, and 30- and 90-day reoperation rates.
The after-conference group showed decreased levels of blood loss and fewer intraoperative complications, deep surgical site infections, and postoperative motor deficits compared with the before-conference group. Readmission and reoperation rates were also lower in the after-conference group at both timepoints studied, 30 days and 90 days after surgery:
- Readmission at 30 days: 3.1% for the after-conference group and 10.2% for the before-conference group (P=0.038)
- Readmission at 90 days: 6.3% for the after-conference group and 15.0% for the before-conference group (P=0.035)
- Reoperations at 30 days: 2.1% for the after-conference group and 8.4% for the before-conference group (P=0.040)
- Reoperations at 90 days: 3.1% for the after-conference group and 12.0% for the before-conference group (P=0.014)
Other factors, such as operative time, length of stay, postoperative transfusion, and neuromonitoring signal loss, were similar between groups.
These findings were presented at the 2022 Annual Meeting of the American Academy of Orthopaedic Surgeons.
The researchers concluded that instituting a multidisciplinary case conference for complex spine surgery patients resulted in decreased 30- and 90-day reoperation and readmission rates as well as fewer intraoperative complications and postoperative deep surgical site infections.
“Spinal deformity surgery is one of the most complicated and high-risk operations in our field,” said the study’s senior author, Charla R. Fischer, MD. Dr. Fischer is an Associate Professor in the Department of Orthopaedic Surgery at NYU Grossman School of Medicine. She is also the Director of Quality and Patient Safety in the Division of Spine Surgery at NYU Langone.
“This single-center study shows how impactful multidisciplinary conferences are before high-risk, complex spinal deformity surgeries. It’s critical for institutions to develop this protocol to achieve the best outcomes for their patients.”
Norris Z, Zabat MA, Ashayeri K, Patel H, Mottole NA, Balouch E, O’Connell BK, Maglaras C, Protopsaltis TS, Buckland AJ, Raman T, Fischer CR. Multidisciplinary Conference for Complex Surgery Leads to Improved Quality and Safety (Paper 664). Presented at the American Academy of Orthopaedic Surgeons’ 2022 Annual Meeting, March 22-26, 2022, Chicago, Illinois.