Revision spine surgery is among the most technically demanding work in the OR, and some spine surgeons have rethought their approaches to these cases.
Three spine surgeons discuss their changes for the better.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker’s invites all spine surgeon and specialist responses.
Next question: How are you using patient-reported outcome measures in real time, and have they ever changed a clinical decision you’d already made?
Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CDT Tuesday, April 28.
Editor’s note: Responses were lightly edited for clarity.
Question: What’s the most consequential revision surgery you’ve changed your approach to? What drove that change?
Philip Saville, MD. Saville Spine (Palm Beach Gardens, Fla.): My approach to adjacent segment disease in cervical spine surgery has evolved to include cervical disc arthroplasty when facet anatomy and stability allows for it. The observation of progressive degenerative changes adjacent to fusions has convinced me of the benefits of motion preservation whenever possible. As cervical disc replacement has become a larger part of my practice relative to fusion, I have become more comfortable with the extent of foraminal decompression required, and techniques utilized to mobilize the disc space. Obviously, this isn’t possible in all cases, but it is certainly something to consider, in my experience.
Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: Revision lumbar surgery for failed back surgery syndrome — particularly when the initial surgery was well-intentioned but the indication was soft.
Early in my career, I approached these cases primarily as technical problems. Failed fusion? Evaluate the hardware, assess the biology, consider extension or revision. The operative planning was rigorous. What I underweighted was the psychological and social architecture of the patient’s pain experience with the years of opioids, the secondary gain and the identity that had formed around being a surgical patient.
The change came from an honest accounting of my own outcomes. Not the cases where the hardware failed or the fusion didn’t take. The harder lesson was recognizing that some revision surgeries that were technically successful didn’t help the patient. The pain persisted. The disability persisted. And I had exposed them to another operation.
Now I approach revision lumbar cases with a much longer preoperative evaluation. I insist on a structured psychology screen. I am involved in pain medicine and physiatry. I have explicit conversations about what surgery can and cannot fix, and I’m willing to tell a patient that a third operation is unlikely to give them their life back even if there’s something on the MRI I could address.
The most consequential change was learning to say that operating again may not be the right answer.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): For many years, the go-to procedure for severe thoracic-lumbar instability and spinal oncological work was the multivariant transcavitary approach. Customarily assisted by a vascular surgeon, these procedures then and currently are recognized as extensive undertakings especially for potential complication rates and both patient recovery and outcomes.
The time interval for such surgical recovery was strenuous for patient and family alike and far exceeded any posterior approach by months. With the furthering and acknowledgement of endoscopic additions to transcavitary procedures, mitigation of intraoperative predicaments may lessen over time. The posturing trends of procedural assignment to discogenic evolution is disquieting especially when finance supersedes the dramaturgy.
Related webinar: The Surgeon’s Perspective: Using Neuromonitoring Data When It Matters Most — a surgeon-led look at how neuromonitoring data drives real-time decisions in the OR. Register here.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
