Complex Spine Protocols: Focused on Quality
David Antezana, M.D., Neurosurgeon
The field of complex adult spinal deformity surgery continues to evolve. Despite significant strides, complication rates remain significant. Other fields, such as cardiac surgery, have developed guidelines and protocols that have led to significant improvements in this area. There has been strong interest in applying such principles of risk stratification to adult spinal deformity surgery, particularly over the last 10 years.
Despite the strong interest and multiple publications on complication avoidance, there have been only three initiatives well published in the literature. While these initiatives have shown a decrease in complication rates, there remains much to be addressed. There is no doubt that using a uniform approach with some standardization that allows for individualization of surgery has led to improvements in our field as it has in others.
Spinal Deformities treated include:
Other complex problems include:
- Previous procedures
- Congenital abnormalities
We have worked on a complex spine protocol to apply some of these principles to our patient population here in Portland. Our initiative includes three arms: preoperative, intraoperative and postoperative periods.
The preoperative arm begins with a clinic visit when a patient is identified as appropriate for the protocol and entered into it. The surgeon and assigned nurse review the patient’s history and physical and supporting data and then enter it on to our data sheet. We affectionately call it, our checklist. The surgeon proposes a procedure to correct the patients’ issues and depending on the complexity of the procedure and the patient’s medical history, the different areas are filled in. These areas include, but are not limited to, planned procedure, ASA score, labs, opioid use, and outcomes measures. The patient is then presented at a multidisciplinary conference attended by surgeons, nurses, PM&R, anesthesia, nutrition and other providers. The appropriateness of the patient and the surgery is reviewed. Decisions are made on how to move forward such as proceeding with surgery, additional work up, or choosing not to proceed.
If the patient is deemed appropriate for surgery, preparations are made, and we proceed with the intraoperative portion of our protocol.
An intraoperative checklist, just as with the preoperative portion, is utilized in order to minimize complications and improve outcomes. Considerations include blood loss, infection, pain, blood pressure control, neuromonitoring, spinal navigation, positioning, embolism precautions, glucose control and graft considerations.
The post-operative phase begins as soon as the patient is taken out of the operating room. A protocol detailing key parameters and goals for neurosurgery patients is reviewed.
The ICU team is consulted and sign out is given. Special attention is given to hemodynamic and neurological stability, pain control, hematocrit and glucose. Appropriate imaging is obtained. Additional attention is given for significant blood loss, CSF leak and neurological compromise. Mobilization commences as soon as possible.
Over the hospitalization, the patient is mobilized with Physical and Occupational therapy; the Foley catheter is discontinued; oral intake is progressed; pain control is addressed. If the hospitalization is extended due to complication or other factors, appropriate tests (e.g.: LE duplex, labs) are ordered to avoid complications.
Once discharged, patients are usually followed 1-2 years with outcomes questionnaires completed (ODI, NDI, SRS-22) to track progress. We are in the process of tabulating our progress to better understand how we can improve. We look forward to fully implementing it in the near future.