Spine surgery [Neurosurgery Wiki]

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====== Spine surgery ======

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[[Spine]] [[surgery]] is taught and practiced within two different surgical disciplines: [[neurological surgery]] and orthopedic surgery
((Post AF, Li AY, Dai JB, et al. Academic productivity of spine surgeons
at United States Neurological Surgery and Orthopedic Surgery Training
Programs. World Neurosurg. 2019;121:e511–8.)).

[[Spinal]] [[surgery]] has become lower risk and more efficacious for complex [[spinal deformities]], and thus more appealing to patients, particularly those for whom conservative treatment is inappropriate or ineffective. Recent innovations and advances in spinal surgery have revolutionized the management of [[spinal deformity]] in elderly patients. 


The clinical entity [[lumbar spinal stenosis]] is the most common reason for spinal surgery in patients 65 years of age and older in the United States.

Recently, intraoperative stereotactic [[navigation]] has become more available in spine surgery. Stereotactic navigation with cone-beam fluoroscopy and CT and the use of the O-arm (Medtronic) 3D imaging with stereotactic computer navigation have been well described for the safe and accurate placement of pedicle screws.

===== History =====

[[Spine surgery history]].

===== Training ===== 

[[Spine surgery training]].

===== Epidemiology =====
Spine [[surgery]] has been growing rapidly as a neurosurgical operation, with an increase of 220% over 15 years. 

===== Types =====

[[Cervical spine surgery]]

[[Complex spine surgery]]

[[Emergency spine surgery]]

[[Endoscopic spine surgery]]

[[Lumbar spine surgery]]

[[Minimally Invasive Spine Surgery]]

[[Pediatric spine surgery]]

[[Robot-assisted spine surgery]]
 
[[Spine fusion]]

[[Thoracic spine surgery]]

[[Oncological spine surgery]]

[[Vertebral augmentation]]




===== Indications =====

The line between [[appropriate]] and #inappropriate_spine_interventions has to be clear; to clarify proper indications, priorities of treatment, and ethical considerations.

Appropriate #Indications are well known to everyone, including:

Progressive #neurological_deficits, to prevent permanent neurological damage and to halt or potentially reverse deterioration.

Symptomatizing spinal #mechanical_instability, of any type, also presents clear indications.

#Intractable_Pain with concordant pathology.

Failure of appropriate #conservative_measures for enough time (3 months).

#Deformity with progressive deterioration.

Inappropriate / Controversial Interventions and Premature Surgery

Surgery is generally inappropriate when:

Uncorrelated Imaging Findings and Symptoms:
· #Incidental_findings: MRI abnormalities without corresponding symptoms.
· Non-specific #LBP: In the absence of deficits, instability, or specific pathology.
· Normal aging #degenerative_changes on imaging that are asymptomatic.

2. Untreated #psychiatric_comorbidities: Active depression, anxiety disorders, or personality disorders predict poor outcomes.

3. #Secondary_gain_factors: Litigation, disability claims, or other secondary gain motivations.

4. Substance #abuse: predict poor surgical outcomes and complications.

5. #Unrealistic_expectations: When patient goals cannot reasonably be achieved with the proposed intervention.

6. Inappropriate #Risk_Benefit Assessment: Appropriate spine surgery decisions require rigorous risk-benefit analysis including:
· Patient-specific factors: Age, comorbidities, bone quality, prior surgeries, and healing capacity.
· Surgical complexity: More extensive procedures carry higher complication rates.
· Expected outcome probability: Realistic assessment of success rates based on the specific pathology and patient factors.

Surgery is #premature when:
Inadequate Trial of Conservative Management:
First-line for non-urgent conditions: Most non-emergent spine conditions warrant 6-12 weeks of conservative care before surgical consideration.
2. Incomplete conservative approach: Failure to comprehensively employ physical therapy, appropriate medications, targeted injections, and lifestyle modifications.
3. Inadequate diagnostic workup: Proceeding to surgery without ruling out non-spinal sources of pain or neurological symptoms.

Appropriate means balancing technological capabilities against patient needs and experience-based practice. The conscientious spine surgeon must remain committed to continuous critical self-assessment, and placing patient welfare above all other considerations.

The power of spine surgery carries the responsibility to use it judiciously. The future lies not in performing more surgeries but in performing the right surgeries for the right patients at the right time.

===== Outcome =====

see [[Spine surgery outcome]].

===== Complications =====

see [[Spine surgery complication]]

===== Length of stay =====

[[Spine surgery length of stay]]
====Evidence====

For the majority of spinal interventions, well-designed prospective, randomized, pragmatic cost-effectiveness studies that address the specific decision-in-need are lacking. Decision analytic modeling allows for the estimation of cost-effectiveness based on data available to date. Given the rising demands for proven value in spine care, the use of decision analytic modeling is rapidly increasing by clinicians and policy makers.

A proper, integrated, clinical, and economic critical appraisal is necessary in the evaluation of the strength of evidence provided by a modeling evaluation. As is the case with clinical research, all options for collecting health economic or value data are not without their limitations and flaws. There is substantial heterogeneity across the 20 spine intervention health economic modeling studies summarized with respect to study design, models used, reporting, and general quality. There is sparse evidence for populating spine intervention models. Results mostly showed that interventions were cost-effective based on $100,000/quality-adjusted life-year threshold. Spine care providers, as partners with their health economic colleagues, have unique clinical expertise and perspectives that are critical to interpret the strengths and weaknesses of health economic models.

Health economic models must be critically appraised for both clinical validity and economic quality before altering health care policy, payment strategies, or patient care decisions.Level of Evidence: 4
((Edwards NC, Skelly AC, Ziewacz JE, Cahill K, McGirt MJ. The Role of Decision
Analytic Modeling in the Health Economic Assessment of Spinal Intervention. Spine
(Phila Pa 1976). 2014 Oct 15;39(22S Suppl 1):S16-S42. PubMed PMID: 25299257.)).

A co-ordinated multidisciplinary pathway with a stratified approach to LBP assessment and care provided a greater proportion of surgery candidates than the conventional referral process. The implementation of such processes may allow surgeons to restrict their practices to patients who are more likely to benefit from their services, thereby reducing wait times and potentially reducing costs.Level of Evidence: 3
((Wilgenbusch CS, Wu AS, Fourney DR. Triage of Spine Surgery Referrals Through a
Multidisciplinary Care Pathway: A Value-Based Comparison With Conventional
Referral Processes. Spine (Phila Pa 1976). 2014 Oct 15;39(22S Suppl 1):S129-S135.
PubMed PMID: 25299256.
)).

In the USA, [[obesity]] rates have significantly increased since 2000. Mirroring this trend, a large proportion of patients undergoing spinal surgery are obese
((Srinivasan D, La Marca F, Than KD, Patel RD, Park P. Perioperative characteristics and complications in obese patients undergoing anterior cervical fusion surgery. J Clin Neurosci. 2013 Dec 14. pii: S0967-5868(13)00658-9. doi:10.1016/j.jocn.2013.11.017. [Epub ahead of print] PubMed PMID: 24472239.)).

see [[spinal fusion surgery]]

====Simulation====
The use of simulation in spinal neurosurgery education is not as ubiquitous in comparison to other neurosurgical subspecialties, but many promising methods of simulation are available for augmenting resident education
((Bohm PE, Arnold PM. Simulation and resident education in spinal neurosurgery. 
Surg Neurol Int. 2015 Feb 26;6:33. doi: 10.4103/2152-7806.152146. eCollection
2015. Review. PubMed PMID: 25745588.)).

====Community====
The spinal surgery community has recently witnessed serious controversies and discussion concerning possible bias in scientific reports on the effects of a commercially available bone morphogenetic protein. This has compromised the standing of this community, and it was the direct reason for performing a study titled
((Fauber J. “Journal Editor’s Bonanza Research Articles Favor- able to Provider of Royalties Appear with Regularity,” Milwaukee Journal Sentinel. 2009.))
((Carragee EJ, Ghanayem AJ, Weiner BK, Rothman DJ, Bono CM. A challenge to integrity in spine publications: years of living dangerously with the promotion of bone growth factors. Spine J. 2011; 11: 463–468. doi: 10.1016/j.spinee.2011.06.001))
((Meier B, Wilson D (2011) Spine Experts Repudiate Medtronic Studies. The New York Times.))
((Meier B (2013) Outside Review of Clinical Data Finds a Spinal Treatment’s Benefit Overstated. The New York Times.)).

===== Cost =====

[[Spine surgery cost]].


===== Spine Surgery Books =====
see [[Spine Surgery Books]].


====Implementation of an enhanced recovery programme in spine surgery====
Minimal literature exists describing the process for development of a Joint Commission comprehensive spine surgery program within a community hospital health system. Components of a comprehensive program include structured communication across care settings, preoperative education, quality outcomes tracking, and patient follow-up. Organizations obtaining disease-specific certification must have clear knowledge of the planning, time, and overall commitment, essential to developing a successful program. Health systems benefit from disease-specific certification because of their commitment to a higher standard of service. Certification standards establish a framework for organizational structure and management and provide institutions a competitive edge in the marketplace
((Koerner K, Franker L, Douglas B, Medero E, Bromeland J. Disease-specific Care:
Spine Surgery Program Development. J Neurosci Nurs. 2017 Aug 16. doi:
10.1097/JNN.0000000000000307. [Epub ahead of print] PubMed PMID: 28817500.
)).
((Popat K, Grasu R, Tatsui C, Bird J, Cahoun J, Cata J, Bhavsar S, Rhines L.
Implementation of an enhanced recovery programme in spine surgery. Clin Nutr
ESPEN. 2016 Apr;12:e47. doi: 10.1016/j.clnesp.2016.02.054. Epub 2016 Apr 1.
PubMed PMID: 28531717.)).


===== Intraoperative neurophysiological monitoring in spine surgery =====
see [[Intraoperative neurophysiological monitoring in spine surgery]].

===== Spine surgery informed consent =====
[[Spine surgery informed consent]]

===== Spine surgery in Italy =====
[[Spine surgery in Italy]]