The HSS Spine Care Model


This article is a portion of a book titled "Challenges, Risks and Opportunities in Today's Spine World "edited by Stephen Hochschuler, MD, Frank Phillips, MD, and Richard Fessler, MD. You can find links to the previous chapters at the end of this article.

Over the next several weeks, we will be looking at various spine care models around the US. In the next two chapters we will be looking at the HSS model.

Care of the spine patient at the Hospital for Special Surgery (HSS) is multidisciplinary. While surgical care is focused primarily on elective, inpatient procedures, it is a team effort centered around patient safety and quality outcomes with emphasis on collegiality and communication. We also strive to allow the greatest access to the most diverse group of patients with spinal pathology.In this review we discuss the systematic approach to spine care with particular focus on the relevant disciplines which contribute to this model. Each section is a summary of an interview conducted with an expert in the spine care model at HSS.

Spine care program and non-operative management of low back pain: Joel Press MD, Physiatrist-in-Chief.

The cornerstone of the spine center concept is to optimize triage such that the patient sees the right practitioner at the right time and ensure they get passed on to a higher level of care if they are not improving.

When a patient first calls with low back pain, they are triaged by a nurse who can refer them to an immediate access spine clinician, either a physical therapist (PT) or nurse practitioner (NP) who sees them within 24-48 hours. This immediate access serves several purposes. First, it allows some control of the patient’s anxiety by ensuring acute access for evaluation. Second, it decreases the reliance on narcotic medications by providing education and exercise-based therapies. Finally, it prevents patient attrition to other potentially lower quality sources of care. This process is overseen by a physiatrist, and red flags are screened to ensure escalation of care if necessary.

Red flags such as previous surgery, or a long history of pain will trigger the clinician to refer the patient to a non-operative spine physician. Additionally, if patients are not improving in 5 visits with the physical therapist then they are automatically referred to this next tier of care. The non-operative physician is typically a neurologist, physiatrist, primary care sports medicine specialist or rheumatologist. At this point advanced imaging and multiple non-operative treatment modalities are considered. An emphasis is again placed on movement to ensure every patient is prescribed exercise. The non-operative physicians also focus on anxiety reduction and on a guided treatment program aimed at improving patient confidence.

At any point along this process, surgeons are always available. Office hours between all levels of practitioners are held in close spatial and temporal proximity. This allows efficient communication between divisions. If any of the spine clinicians have concerns, a surgeon is readily available to make recommendations. Patients may sometimes be seen by multiple providers during the same office visit. As many as 500 patients can be filtered effectively through this triage system with only 1-2 eventually requiring surgery.


Spine Radiology: Richard Herzog MD, Director of Spinal Imaging.

At HSS the spine radiologists are responsible for overall imaging quality assurance, which includes several factors. The first is optimizing magnetic resonance imaging (MRI) protocols to ensure imaging quality as well as modifying these protocols to address specific patient anatomy, prior surgery or suspected pathology. The second is the initial training and ongoing education of the radiology technologists. This begins at the technologists’ onboarding, where they will shadow experienced technologist for several months. The shadowing process ensures that they understand what a high-quality imaging exam is and when sequences need to be repeated. The technologist is then mentored by senior technologists on image production and quality until their training is complete. There is always a continuing dialogue between the technologist and the radiologist with respect to image quality and protocols to answer any questions that may arise.

Quality is also ensured by a robust imaging suite. Time slots at HSS for spine imaging are typically one-half hour and HSS currently has 14 high-field (1.5-3 tesla) magnets in use. Dr. Hollis Potter, Chairman of the Dept. of Radiology, works closely with General Electric to develop and implement new imaging protocols at HSS to improve diagnostic quality.

HSS has dedicated spine protocols aimed at providing the most complete diagnostic information. For example, the lumbar spine is evaluated with 7 sequences: 3 sagittal sequences consisting of T1, T2, and STIR, three axial T2 sequences consisting of T12-L3, L3-S1, L5- S1) and a T2 coronal sequence. Multiple contiguous axial sequences ensure that slices are perpendicular to the central canal and include all spinal anatomy. A STIR sequence is performed on all spine cases to optimize the detection of edema or an edema pattern in any pathological process. The cervical spine is evaluated with 6 sequences: 3 sagittal (T1, T2 and STIR), two T2 axial and one gradient-echo axial. A gradient-echo sequence is useful to differentiate between soft tissue and bone and may be helpful to detect small disc herniations. In the cervical spine, complete coverage is critical. Twenty-two sagittal slices are generated on average to image the entire spine in the sagittal plane. The contiguous T2 axial sequences include from the foramen magnum to at least T1, with no skipped anatomy. Special sequences are used to reduce metal artifacts and motion artifacts when present.

Finally, every MRI examination completed at HSS will be interpreted by a subspecialist radiologist. Each radiologist works closely with HSS spine clinicians to ensure all diagnostic questions are answered. Intraoperative dialogue between the surgeon and radiologist is also possible. This collaboration extends beyond clinical work and into the research arena where research has translated into improved imaging technology, knowledge and ultimately improved patient care.

Medical preoperative evaluation: Chad Craig MD, Medical Director of the Spine Service.

Every patient scheduled for inpatient spinal surgery is evaluated and co-managed perioperatively by an HSS-affiliated internal medicine physician. Additional screening protocols are in place to have patients meet with an anesthesiologist, chronic pain management team, diabetes mellitus care team, an obesity specialist, and complex nursing navigators as indicated. A metabolic bone clinic is also available for those at risk for or suffering from osteoporosis. This later team consists of a nurse practitioner who works with a panel of endocrinologists to optimize bone health perioperatively and long-term. Often this involves the use of anabolic agents such as parathyroid hormone analogs. For urgent and non-elective cases there is an inpatient hospitalist team that evaluates patients prior to surgery as well. There is a focus on co-management with the surgical team throughout the hospital stay, and an emphasis on continuity of care, which is the linchpin of the HSS perioperative approach.

The internal medicine physician is responsible for the systematic approach for preoperative evaluation, which emphasizes a thorough history and examination in the initial evaluation. Targeted testing follows based on clinical indication. Commonly utilized risk stratification tools include the American College of Surgeons National Quality Improvement Program (NSQIP) tool—that estimates a number of perioperative risks, the joint American College of Cardiology and American Heart Association perioperative cardiovascular algorithm (inclusive of the Revised Cardiac Risk Index—RCRI—criteria diabetes insulin dependent, stroke, CAD, CKD >2cr, and peripheral arterial disease). Obstructive sleep apnea (OSA) also increases the risk of post-operative respiratory complications and is routinely screened for in all patients. Such patients are generally indicated for overnight monitoring in the Post-Anesthesia Care Unit. Additional “red flags” questioned for in the medical assessment include the use of opioids, benzodiazepines, oral anticoagulants, and antiplatelets beyond low-dose aspirin. Guidelines are in place at HSS, developed by a multidisciplinary committee, for the appropriate holiday period of these medications prior to surgery. Patients who are opioid-dependent are counseled and have weaning programs initiated by the chronic pain management team. Importantly, the chronic pain management team also routinely communicates with outpatient pain management providers for collateral history and to ensure continuity of care following surgery. Finally, criteria are in place for diabetics and no one can have surgery electively unless their hemoglobin A1c is < 8%. Diabetic patients also meet with the diabetic care team and are followed by a diabetic nurse practitioner throughout their stay.

In addition to the medical evaluation, a social and psychological evaluation is performed by the internist. Patient expectations are assessed to gain insight into what the patient hopes to achieve with their surgery. Ensuring there is a common goal between the treatment team and the patient is critical, and discrepancies are brought to the attention of patient and surgeon as necessary. So-called “yellow flags” are explored and can include such things as psychosocial factors, and an assessment of patient support structures. Finally, sources of anxiety for the patient are explored by asking “what you are most worried about?” The risks of surgery are reviewed carefully as well as the tools (anticoagulation, antibiotics, etc.) which are used to mitigate those risks. This approach helps to ease anxiety, and to improve psychological preparation for surgery.

Based on a combination of the medical screening process as well as the surgery being considered, patients are placed on a clinical pathway. These pathways (level 1-4) are used to standardize the expectations for length of stay from both the staff and patient’s perspective and provide goals for patients to meet throughout the course of their stay. These pathways utilize evidence-based approaches to advancing care and preventing perioperative complications. This helps set goals for the entire care team to ensure a safe and optimal discharge time.

Book: Challenges, Risks and Opportunities in Today’s Spine World
Chapter: The HSS Spine Care Model
Writers: Yoshihiro Katsuura, MD, and Todd Albert, MD

Previous chapters:
Challenges, risks and opportunities in today's spine world
Spine care - Balancing cost with innovation
What are big data and predictive analytics
Predictive Analytics and Machine Learning


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