Making Spine Surgery Safer and More Straightforward for Patients
By Ann-Marie Yost, M.D. & Spine Quality Consultant for Providence Brain and Spine Institute
Undergoing spine surgery is a daunting prospect for most patients. A discussion of risks can be intimidating enough, but is also often overshadowed by advice from friends, relatives and co-workers, much of which may not be applicable. Spine surgery sounds monolithic, but may be done for spinal cord or nerve root compression, mechanical instability, sagittal or coronal imbalance (the S curve of scoliosis or the forward bend of Kyphosis), infection, tumor or disc degeneration. Canal or foraminal stenosis can come from bone spurs, disc herniation, epidural lipomatosis, spondylolisthesis, infection or tumor. So not every patient is having surgery for the same reason or combination of reasons, and that can be difficult to communicate.
The same applies to the safety of surgery. While some surgeries may be more risky than others, some patients have inherently higher risks. Uncontrolled diabetes (HgA1c >= 8), obesity (BMI >=40, or in some cases as low as 30), malnutrition, heart disease, lung disease, sleep apnea, depression, anxiety, uncontrolled hypertension, opioid use and other factors can all influence surgical outcome - both complication rate and PRO (patient reported outcome).
Risk stratification begins with a visit to the pre-op anesthesia clinic where a comprehensive evaluation of a patient’s surgical risks is performed. After a history and exam, speaking to other involved physicians (cardiology, oncology, primary care, etc.) and assessing co-morbidities, the clinic makes recommendations on peri-operative management. The recommendations are relayed to the surgeon, discussed with the patient at the visit and sent out to any other involved physicians.
In addition to other needed labs, a nasal swab is done to look for MSSA or MRSA causing nasal colonization. Staph nasal colonization carries a significantly increased risk of getting a surgical site infection. If infection is found, nasal mupiricin may be prescribed ahead of surgery, or a nasal treatment done the day of surgery (nose to toes protocol) in addition to the Ancef or Vancomycin (in case of PCN anaphylaxsis).
If sleep apnea is a concern, care is taken to ensure that patients are stable on their CPAP as sleep apnea can be exacerbated perioperatively, especially in the setting of narcotic use and/or obesity. Recommendations for safe weight loss can also be given as decreasing BMI helps surgical exposure, decreases risk of infection and helps overall health.
Once patients are screened for elective surgery the procedure is scheduled (this process is truncated in the setting of urgent surgery such as cervical myelopathy), Patients are frequently overwhelmed with the detail involved in pre- and peri-op management. They often fail to remember important issues such as when to stop NSAIDs or other meds. At Providence, we are using Twistle in an effort to help streamline this process for patients.
Twistle provides patient engagement and secure messaging via a phone app to help patients prepare for surgery. A seven, 14, or 30 day protocol can be used, depending on what the surgeon’s office assigns as the appropriate protocol. Twistle will then send appropriate reminders about pre-op medications, showering, activity restrictions and advice and FAQ tailored to the individual. Additional options include appointment reminders, links to informational videos, and the ability for the patient to send in photos of the incision, in case of concern. Taken together, peri-op optimization and the enhanced communication and information provided by Twistle help to make surgery as safe and stress-free as possible.